The nurse is caring for a client who arrives at the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. After obtaining vital signs, the nurse should implement which intervention?
Initiate bilateral intermittent sequential pneumatic compression devices.
Place an indwelling urinary catheter and measure strict intake and output.
Notify the stroke team to assist with acute assessment and management.
Administer aspirin to prevent further clot formation and platelet clumping.
The Correct Answer is C
Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.
Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.
Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.
Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Discussing symptomless partners may give false reassurance, as herpes can be transmitted even when symptoms are not present.
Choice B reason: Notifying sexual partners is crucial for public health and the prevention of further transmission of STIs.
Choice C reason: While it's true that STIs are reported, this does not provide the client with actionable advice for their situation.
Choice D reason: Most contraceptives do not protect against STIs like genital herpes, which is spread by skin-to-skin contact.
Correct Answer is A
Explanation
Choice A: Advise the UAP to resume positioning the client on schedule.
Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.
Choice B: Encourage the UAP to provide comfort care measures only.
Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.
Choice C: Assume total care of the client to monitor neurologic function.
Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.
Choice D: Assign a practical nurse to assist the UAP in turning the client.
Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
