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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.
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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