A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?

Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.

Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.

Choice A rationale
When a client’s blood pressure cannot be measured due to casts on both arms and the client’s position, the most appropriate action for the nurse is to document why the blood pressure cannot be accurately measured at the present time. This is because accurate measurement of blood pressure is crucial for monitoring the client’s health status and making appropriate clinical decisions. If the blood pressure cannot be measured accurately, it is important to document this fact along with the reasons why, so that other healthcare professionals are aware of the situation and can take appropriate action.
Choice B rationale
Advising the UAP to document the last blood pressure obtained on the client’s graphic sheet is not the most appropriate action in this situation. While it might provide some information about the client’s previous blood pressure readings, it does not address the current inability to measure the blood pressure. Furthermore, it could potentially lead to confusion or misinterpretation of the client’s current health status.
Choice C rationale
Demonstrating how to palpate the popliteal pulse with the client supine and the knee flexed is not the most appropriate action in this situation. While palpating the popliteal pulse can provide some information about the client’s circulatory status, it does not provide a measure of blood pressure. Furthermore, this action might not be feasible or appropriate depending on the client’s condition and the presence of casts on both arms.
Choice D rationale
Estimating the blood pressure by assessing the pulse volume of the client’s radial pulses is not the most appropriate action in this situation. While pulse volume can provide some information about the client’s circulatory status, it does not provide a measure of blood pressure. Furthermore, this method of estimating blood pressure is not as accurate or reliable as direct measurement.