A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech.
Which of the following actions should the nurse take?

Call emergency medical services.

Find a location for the client to sit.

Drive the client to the nearest emergency room.

Obtain the number of the client's provider.

Answer and Explanation

The Correct Answer is A

The nurse should call emergency medical services if they find a woman who has collapsed with right-sided weakness and slurred speech. These symptoms could indicate a stroke or other serious medical condition that requires immediate medical attention.

Finding a location for the client to sit, driving the client to the nearest emergency room, and obtaining the number of the client's provider are not appropriate initial actions for the nurse to take in this situation. The priority is to get the client immediate medical attention by calling emergency medical services.

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Correct Answer is D

Explanation

a. Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
b. External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.

c.Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.

d. In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.

A. The client requires total nursing care. B. The client is in a deep coma. C. The client is alert and oriented. D. The client has a stable neurological status.

Correct Answer is A

Explanation

a.A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.

b.A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.

c.A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.

d.A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.

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A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

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A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech.
Which of the following actions should the nurse take?