A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Perform carotid massage.

Call for help.

Provide the client with water to test the gag reflex.

Administer thrombolytics.

Answer and Explanation

The Correct Answer is B

Choice A reason: Performing carotid massage is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may worsen the condition or cause complications. Carotid massage is a technique that involves applying pressure to the carotid artery in the neck to stimulate the vagus nerve and slow down the heart rate. It is used to treat some types of arrhythmias, such as supraventricular tachycardia. However, carotid massage may dislodge a blood clot or plaque from the carotid artery and cause an embolic stroke, which is a type of ischemic stroke that occurs when a blood clot travels to the brain and blocks a blood vessel. Carotid massage may also cause bradycardia, hypotension, or syncope, which can reduce the blood flow to the brain and worsen the ischemic damage.

Choice B reason: Calling for help is an appropriate action for a nurse to take when a client has signs of a stroke, as it initiates the emergency response and allows for prompt evaluation and treatment. Stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. The sooner the stroke is recognized and treated, the better the chances of survival and recovery. Therefore, the nurse should call for help as soon as possible and activate the stroke protocol in the facility.

Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may cause aspiration or choking. A gag reflex is an involuntary contraction of the throat muscles that prevents foreign objects from entering the airway. It is tested by touching the back of the throat with a tongue depressor or a cotton swab. However, this test is not indicated in a client who has signs of a stroke, as it may trigger vomiting or coughing, which can increase intracranial pressure or cause bleeding. Moreover, giving water to a client who has signs of a stroke may be dangerous, as they may have dysphagia (difficulty swallowing) or facial weakness, which can impair their ability to swallow safely and increase the risk of aspiration pneumonia.

Choice D reason: Administering thrombolytics is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may be contraindicated or harmful depending on the type and timing of the stroke. Thrombolytics are medications that dissolve blood clots and restore blood flow. They are used to treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, thrombolytics are not effective for hemorrhagic stroke, which is caused by bleeding into or around the brain. In fact, thrombolytics may worsen hemorrhagic stroke by increasing bleeding and intracranial pressure. Therefore, thrombolytics should only be given after confirming the type of stroke by imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Thrombolytics should also be given within a specific time window after the onset of symptoms, usually within 3 to 4.5 hours, as they may lose their effectiveness or cause complications if given too late. Therefore, administering thrombolytics is not an action that a nurse can take without proper assessment and orders from the health care provider.

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Correct Answer is D

Explanation

Choice A: Encourage community members to practice fire drills. This is incorrect because fire drills are a part of the preparedness phase, not the prevention/mitigation phase. The prevention/mitigation phase aims to reduce the risk and impact of disasters, while the preparedness phase aims to enhance the readiness and response capacity of individuals and communities.

Choice B: Identify community members who have disabilities. This is incorrect because identifying community members who have disabilities is also a part of the preparedness phase, not the prevention/mitigation phase. The prevention/mitigation phase focuses on actions that can prevent or minimize the occurrence or effects of disasters, such as installing smoke detectors, reinforcing buildings, or creating evacuation routes.

Choice C: Provide first aid to community members affected by a tornado. This is incorrect because providing first aid to community members affected by a tornado is a part of the response phase, not the prevention/mitigation phase. The response phase involves immediate actions to save lives, protect property, and meet basic needs after a disaster occurs.

Choice D: Assist community members in developing a disaster plan. This is correct because assisting community members in developing a disaster plan is a part of the prevention/mitigation phase. A disaster plan can help identify potential hazards, assess vulnerabilities, establish goals and objectives, and implement strategies to reduce the risk and impact of disasters.

A. Complete a survey of the various ethnicities represented in the nurse's community. B. Study the beliefs and traditions of persons living in other cultures. C. Consider how the nurse's own personal beliefs and decisions are reflective of their culture. D. Invite a family from another culture to join the nurse for an event.

Correct Answer is C

Explanation

Choice A reason: Completing a survey of the various ethnicities represented in the nurse's community is a good way to learn about diversity, but it is not the first step in developing cultural competence. The nurse should first examine their own cultural background and biases, and how they affect their interactions with clients.

Choice B reason: Studying the beliefs and traditions of persons living in other cultures is a valuable way to gain knowledge and understanding, but it is not the first step in developing cultural competence. The nurse should first be aware of their own cultural values and assumptions, and how they influence their perceptions and judgments.

Choice C reason: Considering how the nurse's own personal beliefs and decisions are reflective of their culture is the first step in developing cultural competence. The nurse should recognize that culture is not only about ethnicity, but also about age, gender, religion, education, socioeconomic status, and other factors. The nurse should also acknowledge that culture is dynamic and complex and that each person has a unique cultural identity.

Choice D reason: Inviting a family from another culture to join the nurse for an event is a nice way to show respect and interest, but it is not the first step in developing cultural competence. The nurse should first develop self-awareness and sensitivity, and avoid making stereotypes or generalizations about other cultures.

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