Exhibits

The nurse is stabilizing the client and preparing her for surgery.
Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access. Inserting a central line would not address the underlying issue of compromised airway patency, and it would delay necessary interventions to secure the airway.

Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction. In the context of a client experiencing stridor, the priority is to ensure a patent airway, not to manage gastrointestinal issues. NGT insertion could potentially exacerbate airway compromise in a client with stridor.

Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation. This procedure is particularly important in cases where upper airway obstruction is suspected, such as swelling or hematoma formation following neck surgery.

Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction. The immediate concern for a client with stridor is ensuring a patent airway, and pacemaker placement would not resolve the airway compromise.

Condition: Transient ischemic stroke (d)

2 actions:

1. Request a prescription for a computerized tomography (CT) scan of the client's head and neck (d)
2. Perform a National Institute of Health Stroke Scale (NIHSS) assessment (e)

2 parameters:

1. Neurological status (a)
2. Blood pressure (c)

Rationale for correct condition: A transient ischemic stroke (TIA) is a temporary period of symptoms similar to those of a stroke and is often a precursor to a full-blown stroke. The patient's symptoms of dizziness, weakness, and a horrible headache, combined with his history of hypertension and atrial fibrillation, suggest a high risk for a TIA. The patient's confusion about the date and time also supports this condition. Immediate assessment and intervention are crucial to prevent a possible stroke.

Rationale for the two correct actions:

1. Request a prescription for a CT scan: This is essential to identify any blockages or abnormalities in the blood vessels of the brain, confirming the presence and extent of a TIA or stroke.
2. Perform an NIHSS assessment: This standardized tool is used to evaluate the severity of a stroke and to monitor changes in the patient's neurological status over time.

Rationale for parameters to monitor:

1. Neurological status: Monitoring this parameter helps track changes in the patient's cognitive and motor functions, which are critical in assessing the progression or improvement of the stroke symptoms.
2. Blood pressure: Hypertension is a major risk factor for strokes. Keeping a close watch on the blood pressure helps in managing and reducing the risk of further complications.

Rationale for incorrect conditions:

1. Hypoglycemia: While it can cause dizziness and weakness, the patient's recent UTI and headache are not typical for hypoglycemia.
2. Hemorrhagic stroke: This would typically present with more severe neurological symptoms and possible loss of consciousness.
3. Urinary tract infection: The patient's symptoms go beyond those of a UTI, especially given the headache, dizziness, and confusion.

Rationale for incorrect actions to take:

1. Administer 0.9% sodium chloride IV: Not specific to stroke management and doesn't address the immediate risk.
2. Administer oxygen via nasal cannula: The patient's oxygen saturation is normal; thus, this is not immediately necessary.
3. Request a prescription for the client's home medication of aspirin: While aspirin is used for stroke prevention, administering it without confirming the stroke type (ischemic vs hemorrhagic) could be harmful.

Rationale for incorrect parameters to monitor:

1. Respiratory rate: This is not directly related to stroke assessment.
2. Urine output: Irrelevant to the immediate management of TIA.
3. Oxygen saturation: The patient's oxygen levels are normal, so monitoring it won't provide further insights.