An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm.

After confirming the presence of the spasms, which action should the nurse take?

Choice A rationale:

Beginning continuous observation for transient episodes of neurologic dysfunction is important in the assessment and monitoring of the client's condition. However, in this scenario, the client is presenting with symptoms suggestive of a possible stroke or cerebrovascular event, and time is crucial. The nurse should prioritize actions that can lead to prompt diagnosis and treatment.

Choice B rationale:

Starting two large bore intravenous (IV) catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the most urgent action. The client's symptoms, including sudden right-sided numbness, weakness, and facial droop, are indicative of a possible ischemic stroke. IV fibrinolytic therapy is time-sensitive and has a limited window of effectiveness. Establishing IV access and determining eligibility for this therapy should be the nurse's top priority to potentially improve the client's outcome.

Choice C rationale:

Administering aspirin to prevent further clot formation and platelet clumping is an important intervention in the treatment of ischemic stroke. However, it should not be the first action in this scenario. The priority is to assess for eligibility for IV fibrinolytic therapy, as this intervention has a more immediate impact on reversing the stroke's effects.

Choice D rationale:

Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is a reasonable nursing intervention to prevent complications such as aspiration and promote optimal cerebral blood flow. However, it is not the most urgent action in this case. The priority should be on assessing and potentially treating the stroke with IV fibrinolytic therapy.

Choice A rationale:

Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.

Choice B rationale:

Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.

Choice C rationale:

Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.

Choice D rationale:

Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.