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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
While switching to less anxiety-provoking questions might help in some situations, it does not address the immediate issue of the client undressing inappropriately.
Choice B rationale
Ignoring the client’s inappropriate behavior could potentially encourage further inappropriate actions and does not respect the therapeutic boundaries necessary in a nurse-client relationship.
Choice C rationale
Leaving the client’s room might escalate the situation further and does not address the immediate issue.
Choice D rationale
The nurse should assertively but respectfully communicate that undressing is not appropriate during the interview. This sets clear boundaries and expectations for the client’s behavior.

A. How do you cope with the voices? B. When do you hear the voices? C. Which medication works best for you? D. What are the voices saying?

Correct Answer is D

Explanation

Choice A rationale

While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations.

Choice B rationale

The timing of the voices can provide some insight into the triggers or patterns of the hallucinations, but it does not directly address the content or potential impact of the hallucinations on the client’s behavior or mental state.

Choice C rationale

While medication efficacy is an important aspect of managing schizophrenia, it does not directly address the current experience of the client’s hallucinations.

Choice D rationale

Understanding what the voices are saying to the client can provide critical information about potential risks, including self-harm or harm to others, and can guide the treatment plan. This is why it is the most important question for the nurse to include in the client’s assessment.

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Naxlex Comprehensive Predictor Exams

While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room. What should be the nurse’s initial action?

Correct Answer is D

Explanation

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

Correct Answer is D

Explanation

A patient with diabetic peripheral neuropathy has been taking pregabalin for the past four days. Which finding would indicate to the nurse that the medication is effective?

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most crucial for the nurse to implement?

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. What two actions should the nurse take first during the primary survey?