A nurse is caring for a patient who suddenly experiences right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the 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.

Begin continuous observation for transient episodes of neurological 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
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.

Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.

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Correct Answer is A

Explanation

Choice A rationale

Inquiring about the frequency of falls in recent months is an important part of a functional assessment for an older adult patient reporting decreased strength in knees and handgrips. Falls can be a sign of decreased muscle strength and balance, which can be associated with aging and certain medical conditions.

Choice B rationale

Sundowning, or increased confusion and agitation in the late afternoon and evening, is a symptom often associated with dementia, not necessarily with decreased strength in knees and handgrips.

Choice C rationale

While discussing end-of-life care options is an important aspect of comprehensive patient care, it is not directly related to the patient’s reported symptoms of decreased strength.

Choice D rationale

Requesting the patient to lie as still as possible for the assessment may not provide comprehensive information about the patient’s functional mobility and strength.

A. Teach the client how to use guided imagery B. Instruct the client and family to reconsider end of life choices C. Record the client’s desire to live D. Encourage the family to bring the client old photographs E. Encourage the family to visit frequently .

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale
Teaching the client how to use guided imagery can be a helpful intervention for coping with feelings related to death and dying. Guided imagery can help the client to relax, reduce stress and anxiety, and find comfort.

Choice B rationale
Instructing the client and family to reconsider end of life choices is not typically an appropriate intervention. The nurse should respect the client’s end of life choices and provide support, rather than suggesting they reconsider.
Choice C rationale
Recording the client’s desire to live is not typically an intervention used in hospice care. The focus in hospice care is on providing comfort and quality of life, rather than on prolonging life.
Choice D rationale
Encouraging the family to bring the client old photographs can be a helpful intervention. Looking at old photographs can stimulate memories and conversations, providing comfort and connection.
Choice E rationale
Encouraging the family to visit frequently can be a beneficial intervention. Frequent visits can provide the client with emotional support and companionship, which can be comforting when coping with feelings related to death and dying.

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Naxlex Comprehensive Predictor Exams

An older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

Correct Answer is A

Explanation

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

When formulating a nursing care plan for a client diagnosed with Parkinson’s disease, which nursing problem should be given the highest priority?

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