The nurse is caring for a client who reports a sudden, severe headache, and facial numbness.The nurse asks the client to smile and observes an uneven smile with a 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. After obtaining vital signs, the nurse should implement which intervention?
Place an indwelling urinary catheter and measure strict intake and output.
Maintain elevated positioning of the dependent joints on affected side.
Raise the head of the bed to 30 degrees keep head and neck in neutral alignment.
Determine when symptoms began and if improved or worsened since onset.
The Correct Answer is D
A) Incorrect- While monitoring urinary output is important for overall assessment, it is not the most critical intervention in this situation of suspected stroke. The client's neurological symptoms take precedence.
B) Incorrect- Positioning might be relevant to preventing complications, but it is not the highest priority intervention in this situation. The focus should be on assessing the client's neurological status and determining appropriate intervention.
C) Incorrect- Although head positioning is relevant for intracranial pressure management, it is not the immediate priority. The nurse should first assess the time of symptom onset and determine if the client is experiencing an acute stroke.
D) Correct- The client's symptoms, including sudden severe headache, facial numbness, facial droop, and weakness on one side, are suggestive of a stroke. The nurse should prioritize assessing the time of symptom onset, as time is a crucial factor in determining the appropriate intervention. Rapid intervention can improve outcomes in stroke cases, especially when considering interventions like thrombolytic therapy. The other options are not as directly relevant to the immediate management of a suspected stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
The level of hypoxemia that the child may have experienced during the submersion depends on several factors, but the most important ones are:
- The **temperature of water**: Cold water can induce a diving reflex, which lowers the heart rate and oxygen consumption, and may protect the brain from hypoxic injury¹². Cold water can also cause laryngospasm, which prevents water aspiration but also impairs gas exchange.
- The **amount of time the child was submerged**: The longer the submersion, the more severe the hypoxemia and the higher the risk of brain damage and death. The survival rate decreases significantly after 5 minutes of submersion³.
The other factors are less relevant or not directly related to the level of hypoxemia:
- The **weight of the child**: This may affect the buoyancy and the ability to float or swim, but not the oxygen consumption or gas exchange during submersion¹.
- The **oxygen concentration of the ambient air**: This may affect the pre-submersion oxygen saturation, but not the rate of oxygen depletion or gas exchange during submersion¹.
- The **witnessing of the fall into the pool**: This may affect the time to rescue and resuscitation, but not the level of hypoxemia during submersion.
Correct Answer is B
Explanation
The Herpes zoster (shingles) vaccination is recommended for adults aged 60 years and older, regardless of whether they have had shingles or chicken pox before. The vaccine can reduce the risk of developing shingles and its complications, such as postherpetic neuralgia.
The other options are not correct because:
a. The vaccine is useful even if the person has had a case of shingles before, as shingles can recur in some people. The vaccine can prevent or reduce the severity of future episodes.
c. The person needs to get this vaccination even if they have had chicken pox, as shingles is caused by the reactivation of the same virus that causes chicken pox (varicella-zoster virus). The vaccine can boost the immunity against the virus and prevent it from reactivating.
d. The vaccination does not minimize outbreaks of cold sores, as cold sores are caused by a different virus (herpes simplex virus). The vaccine has no effect on this virus or its symptoms.
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