A nurse is attending to a patient who suddenly experiences numbness and weakness on the right side of their body, including their arm and leg.
The nurse also observes a distinct droop on the right side of the patient’s face.
After reporting these findings to the healthcare provider, the nurse receives several prescriptions for the patient, including an immediate CT scan of the head.
What should be the nurse’s first course of action?
Initiate two large-bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy.
Start continuous observation for transient episodes of neurologic dysfunction.
Elevate the head of the bed to 30 degrees, keeping the head and neck in neutral alignment.
Administer aspirin to prevent further clot formation and platelet aggregation.
The Correct Answer is A
Choice A rationale
If a patient suddenly experiences numbness and weakness on the right side of their body, including their arm and leg, and a distinct droop on the right side of the patient’s face, these are warning signs of a stroke. The nurse’s first course of action should be to initiate two large- bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy. This is because rapid administration of fibrinolytic therapy can significantly improve outcomes in patients with acute ischemic stroke.
Choice B rationale
Continuous observation for transient episodes of neurologic dysfunction is important, but the immediate priority is to prepare for potential fibrinolytic therapy.
Choice C rationale
Elevating the head of the bed to 30 degrees and keeping the head and neck in neutral alignment can be beneficial in certain situations, but it is not the immediate priority in this scenario.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with acute coronary syndrome or those at high risk of cardiovascular disease.
However, in the case of a suspected stroke, immediate medical evaluation and potential fibrinolytic therapy are the priorities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
Seeking clarification of the type of advance directive the client has is the most appropriate response. A living will typically outlines a person’s wishes for end-of-life care, but it may not specifically address emergency situations like cardiac arrest.
Choice A rationale
Scheduling a client and family conference to review the plan of care may be helpful, but it is not the immediate priority. The nurse first needs to understand the client’s wishes as outlined in their advance directive.
Choice B rationale
Explaining that living wills cannot be followed by emergency personnel is not entirely accurate. While it’s true that emergency personnel initiating resuscitative measures may not have immediate access to a person’s living will, in a hospital setting, a person’s known wishes should be respected as much as possible.
Choice C rationale
Checking the client’s arm for a “Do Not Resuscitate” (DNR) bracelet is not the most appropriate response. While some people may choose to wear such a bracelet, not all do. Furthermore, a DNR order is just one type of advance directive, and it’s important to clarify what specific directives the client has in place.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Weighing the client daily, in the morning, is an important intervention for a client with heart failure (HF) being treated with diuretics for fluid volume excess. Daily weights can help monitor the client’s fluid status and the effectiveness of the diuretic therapy.
Choice B rationale
Teaching the client how to restrict dietary sodium is an important intervention for a client with HF being treated with diuretics for fluid volume excess. A low-sodium diet can help prevent fluid retention and exacerbation of HF3.
Choice C rationale
Monitoring coagulation laboratory values is not typically necessary for a client with HF being treated with diuretics for fluid volume excess, unless the client is also receiving anticoagulant therapy.
Choice D rationale
Observing for evidence of hypokalemia is an important intervention for a client with HF being treated with diuretics for fluid volume excess. Diuretics can cause loss of potassium, which can lead to hypokalemia.
Choice E rationale
Encouraging an oral fluid intake of 3,000 mL/day is not typically recommended for a client with HF being treated with diuretics for fluid volume excess. Excessive fluid intake can exacerbate HF3.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.