The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left.
The client denies a recent history of headaches or trauma.
Which intervention should the nurse perform immediately?
Maintain elevated positioning of the dependent joints on the affected side.
Verify prescribed laboratory tests include prothrombin time and platelet count.
Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
Administer aspirin to prevent further clot formation and platelet clumping.
The Correct Answer is C
Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Blood pH level is a measure of the acidity or alkalinity of the blood. While it’s an important measure in many medical situations, it’s not directly related to the presence of purulent drainage at a burn wound site.
Choice B rationale
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
Choice C rationale
The White Blood Cell (WBC) count is a key indicator of infection or inflammation in the body. An elevated WBC count can indicate an infection, which could be the cause of the purulent drainage observed at the burn wound site.
Choice D rationale
Platelet count is a measure of the number of platelets in the blood. Platelets are involved in clotting and wound healing, but they do not directly indicate the presence of an infection that could cause purulent drainage.
Correct Answer is A
Explanation
Choice A rationale
The client’s presentation of chest pain radiating to the left arm, shortness of breath, and diaphoresis are classic symptoms of a myocardial infarction (heart attack)56. Morphine is often administered in this situation to relieve pain and reduce the workload of the heart.
Choice B rationale
Oxycodone is a strong opioid medication used to treat severe pain. However, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Choice C rationale
Hydromorphone is another strong opioid medication used to treat severe pain. Like oxycodone, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Choice D rationale
Fentanyl is a potent opioid pain reliever. While it can be used in the management of severe pain, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
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