A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

The client is consuming 25% of their meals.

The client coughs frequently while eating.

The client's blood pressure is 142/94 mm Hg.

The client leans to the left side while sitting.

Answer and Explanation

The Correct Answer is B

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

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Correct Answer is D

Explanation

A. A feeling of swelling in the feet:

Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.

B. Pain at the injection site:

Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.

C. A sudden decrease in heart rate:

An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.

D. A sharp decrease in blood pressure:

This is the correct answer. Anaphylactic reactions can lead to a sudden and severe drop in blood pressure, which is a critical and life-threatening symptom. This is due to the release of vasodilatory substances and increased permeability of blood vessels, resulting in a decrease in blood volume within the vessels.

Anaphylactic Shock: A life-threatening reaction | Henrylito D. Tacio

A. Elevate full-length side rails on both sides of the client's bed. B. Place the bedside table 0.9 m (3 feet) away from the bed. C. Keep the client's room temperature at 18° C (64.4" F). D. Provide the client with a night light.

Correct Answer is D

Explanation

A. Elevate full-length side rails on both sides of the client's bed:

While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.

B. Place the bedside table 0.9 m (3 feet) away from the bed:

Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.

C. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.

D. Provide the client with a night light:

This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.

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A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

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