The nurse is caring for a client who arrives to 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. The nurse should immediately take which action?
Keep the bed in the lowest position and initiate seizure and fall precautions.
Place an indwelling urinary catheter and measure strict intake and output.
Maintain elevated positioning of the dependent joints on affected side.
Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
The Correct Answer is D
Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.
Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.
Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Measuring abdominal girth is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be useful for monitoring fluid status and abdominal distension.
Choice B reason: Assessing perineal area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be important for maintaining hygiene and preventing infection.
Choice D reason: Palpating flank area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be helpful for detecting kidney tenderness or enlargement.
Correct Answer is D
Explanation
Choice A: Creatinine is not a relevant laboratory test for the nurse to monitor, as this reflects renal function and is not affected by naproxen or arthritis. This is a distractor choice.
Choice B: Serum calcium is not a pertinent laboratory test for the nurse to monitor, as this indicates bone metabolism and is not related to naproxen or arthritis. This is another distractor choice.
Choice C: Erythrocyte sedimentation rate is not an important laboratory test for the nurse to monitor, as this measures inflammation and is not influenced by naproxen or stomach pain. This is another distractor choice.
Choice D: Hemoglobin is an essential laboratory test for the nurse to monitor, as this shows blood oxygen-carrying capacity and can be reduced by naproxen-induced gastrointestinal bleeding, which can cause stomach pain, weakness, and fatigue. Therefore, this is the correct choice.
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