The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

Obtain an electrocardiogram (ECG) exam

Obtain intravenous access

Administer 2 L of oxygen per nasal cannula

Obtain a rectal temperature

Answer and Explanation

The Correct Answer is C

A. Obtain an electrocardiogram (ECG) exam: While an ECG is important to assess cardiac status, it is not the immediate priority compared to addressing the low oxygen saturation.
B. Obtain intravenous access: IV access is important for administering medications and fluids but does not take precedence over addressing hypoxia.
C. Administer 2 L of oxygen per nasal cannula: This is correct. The priority is to improve oxygenation since hypoxia can exacerbate neurological damage in a stroke patient. An SpO2 of 88% is low and requires immediate correction to prevent further complications.
D. Obtain a rectal temperature: Temperature assessment is not as urgent as addressing the immediate need for oxygen to improve SpO2 levels.

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Correct Answer is B

Explanation

A. Increase the client's oral fluid intake.: While staying hydrated is generally good, it doesn't directly address the issue of cold feet caused by reduced circulation.
B. Obtain a pair of slipper socks for the client.: Slipper socks can help keep the feet warm without constricting blood flow, which is important for comfort and promoting circulation.
C. Rub the client's feet briskly for several minutes.: Vigorous rubbing could potentially cause injury or worsen circulation issues due to the fragility of the tissues in vascular compromise.
D. Place a moist heating pad under the client's feet.: Moist heat is not recommended as it can increase the risk of burns and injury, especially if the client has reduced sensation due to vascular occlusion.

A. Transient ischemic attack B. Basilar artery syndrome C. Left middle cerebral artery syndrome D. Right middle cerebral artery syndrome

Correct Answer is C

Explanation

A. Transient ischemic attack (TIA): A TIA might cause transient symptoms similar to a stroke, including weakness and dysphasia, but it would not explain why the symptoms are localized to the right side of the body. Additionally, TIA symptoms typically resolve within 24 hours.
B. Basilar artery syndrome: This type of stroke affects the brain stem, resulting in symptoms such as double vision, vertigo, and ataxia, rather than localized right-sided weakness and dysphasia.
C. Left middle cerebral artery syndrome: The left middle cerebral artery (MCA) supplies blood to the left hemisphere of the brain, including areas that control language and motor function on the right side of the body. Thus, an infarct in this area often leads to right-sided weakness and dysphasia, making it the most likely suspect.
D. Right middle cerebral artery syndrome: This would typically result in left-sided weakness and possibly neglect, but not right-sided symptoms

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The nurse assists with care of a confused patient who presents to the emergency department with stroke symptoms. Vital signs are blood pressure 174/100 mm Hg. pulse 64 beats per minute, and SpO2 88% on room air. Which nursing intervention is priority?

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Naxlex Comprehensive Predictor Exams

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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