A nurse is caring for a 77-year-old African American male client in the emergency department.

Exhibits

Based on the clients progression. Which of the following actions should the nurse take? Select all that apply:

Choice A rationale: The nurse should prepare to administer tissue plasminogen activator (tPA). This medication is used to dissolve blood clots that have formed in the blood vessels of the brain. The client’s CT scan shows a large area of decreased attenuation in the left hemisphere, which is indicative of a stroke. The administration of tPA is time-sensitive and should be initiated as soon as possible after the onset of symptoms if there is no evidence of hemorrhage on the CT scan.

Choice B rationale: Positioning the client on his right side is not necessarily beneficial in this situation. The client is experiencing symptoms of a stroke, and positioning will not alleviate these symptoms. It is more important to focus on interventions that can potentially reverse the effects of the stroke, such as the administration of tPA.

Choice C rationale: There is no indication that the client requires a bolus of 50% dextrose. The client’s blood glucose levels are within normal limits, and hypoglycemia is not a concern at this time. Administering a bolus of 50% dextrose without indication could potentially lead to hyperglycemia.

Choice D rationale: The nurse should anticipate the need for endotracheal intubation. The client’s condition is deteriorating, and he is now unresponsive to verbal stimuli and only responds to painful stimuli. This indicates a decreased level of consciousness, which can compromise the client’s airway. Endotracheal intubation may be necessary to protect the client’s airway and ensure adequate ventilation.

Choice E rationale: The nurse should prepare to administer antihypertensive medication. The client’s blood pressure is significantly elevated, which can further exacerbate the damage caused by a stroke. Antihypertensive medication can help to lower the client’s blood pressure and reduce the risk of further complications.

Choice F rationale: The nurse should use a calm and reassuring approach when interacting with the client. This can help to reduce anxiety and promote a sense of safety. It is important to remember that the client may be scared and confused due to his symptoms, and a calm and reassuring approach can help to alleviate these feelings.

Choice G rationale: Restricting all fluids and sodium intake is not indicated in this situation. While fluid and sodium balance is important in stroke patients, there is no indication that the client is fluid overloaded or has a condition that would require sodium restriction. Furthermore, the client has been prescribed IV fluids, indicating that fluid restriction is not appropriate at this time.

Choice A rationale: Clients with epilepsy are at high risk of injury from falls during seizures due to sudden loss of consciousness or motor control. Climbing ladders increases the risk of severe trauma, including head injuries and fractures, if a seizure occurs at height. The American Epilepsy Society recommends avoiding elevated surfaces without safety measures. Neurological unpredictability in epilepsy necessitates minimizing exposure to high-risk environments to prevent secondary injuries during seizure episodes.

Choice B rationale: Swimming alone is contraindicated for clients with epilepsy due to the risk of drowning if a seizure occurs in water. A partner can provide immediate assistance, ensuring airway patency and preventing submersion. The CDC and Epilepsy Foundation emphasize supervised aquatic activity. Seizures may cause loss of consciousness or muscle control, making it impossible for the individual to self-rescue. Even brief seizures can lead to aspiration or hypoxic injury if not promptly addressed by a nearby observer.

Choice C rationale: Driving restrictions for clients with epilepsy vary by jurisdiction, but most guidelines, including those from ATI and the Epilepsy Foundation, recommend a seizure-free period of 6 to 12 months before resuming driving. This is based on the risk of sudden incapacitation while operating a vehicle, which endangers both the driver and the public. A 3-month seizure-free period is insufficient and not evidence-based. Neurological stability must be demonstrated over a longer duration to ensure safety.

Choice D rationale: Power tools pose a significant hazard to individuals with epilepsy due to the potential for sudden seizure activity during operation. These tools often involve sharp, fast-moving components that can cause severe injury if control is lost. The Occupational Safety and Health Administration (OSHA) advises against unsupervised use of such equipment by individuals with seizure disorders. Seizure unpredictability necessitates avoiding machinery that requires continuous attention and motor coordination to prevent traumatic injuries.

Choice E rationale: During a seizure, especially a generalized tonic-clonic seizure, it is critical to gently guide the client to the floor to prevent injury from falling. This position helps reduce the risk of head trauma and allows for safer seizure progression. The floor provides a stable surface, minimizing the chance of secondary injury. The nurse should also clear the area of sharp objects and cushion the head to protect the client during convulsions, as recommended by seizure first aid protocols.

Choice F rationale: Positioning a client on their back during postictal recovery is contraindicated due to the risk of airway obstruction. Seizures often result in decreased consciousness, increased oral secretions, or vomiting. The supine position can lead to aspiration or hypoxia. Instead, the recovery position—lying on the side—facilitates drainage of secretions and maintains airway patency. The American Red Cross and Epilepsy Foundation recommend side-lying recovery to reduce respiratory complications and promote safe postictal recovery.