A client with new onset right-sided weakness is admitted to the emergency department and the following orders are received. Which order should the nurse implement first?

Aspirin 325mg po

Non-contrast computed tomography (CT) scan

Electrocardiogram (ECG)

Simvastatin (Zocor) 80 mg po

Answer and Explanation

The Correct Answer is B

A. Aspirin 325 mg PO: Aspirin is important for preventing clot formation but should not be administered until a hemorrhagic stroke is ruled out.

B. Non-contrast computed tomography (CT) scan: This is the priority because it determines whether the stroke is ischemic or hemorrhagic, guiding further treatment.

C. Electrocardiogram (ECG): While assessing cardiac rhythm is important, it is not the immediate priority in the presence of stroke symptoms.

D. Simvastatin (Zocor) 80 mg PO: Statins are used for long-term management but are not urgent in this acute scenario.

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Correct Answer is D

Explanation

A. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. Hyperventilation can reduce ICP by causing vasoconstriction of cerebral blood vessels; however, a PaCO2 as low as 15–20 mmHg may lead to excessive vasoconstriction, reducing cerebral blood flow and causing cerebral ischemia. A PaCO2 target closer to 30–35 mmHg is typically recommended, and even this is used cautiously.

B. Routinely suction to prevent accumulation of respiratory secretions. Suctioning can increase ICP due to stimulation of the cough reflex. It should be performed only as needed and in a way that minimizes stimulation, such as preoxygenation and limiting suction duration.

C. Encourage visitation to prevent feelings of isolation. While social support is important, minimizing environmental stimuli (including limiting visitation) is crucial for clients with increased ICP to prevent overstimulation and further increases in ICP.

D. Avoid positioning the client with neck and hip flexion. Maintaining proper alignment of the head and neck is essential to promote venous drainage and reduce intracranial pressure (ICP). Flexion of the neck or hips can impede venous outflow, exacerbate ICP, and compromise cerebral perfusion.

A. Auscultate for a pericardial friction rub B. Inspect the skin for petechia C. Palpate the radial pulses bilaterally D. Assess for abdominal pain

Correct Answer is A

Explanation

A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.

B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.

C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.

D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.

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A client with new onset right-sided weakness is admitted to the emergency department and the following orders are received. Which order should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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