The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head.
After obtaining vital signs, the nurse should implement which intervention?
Keep the bed in the lowest position and initiate seizure and fall precautions.
Administer aspirin to prevent further clot formation and platelet clumping.
Notify the stroke team to assist with acute assessment and management.
Test for a swallowing reflex and perform communication deficit assessments.
The Correct Answer is C
Based on the client's sudden right-sided numbness, weakness of the arm and leg, and distinct right-sided facial droop, the nurse should suspect a possible stroke and prioritize immediate interventions. After reporting the findings to the healthcare provider and receiving prescriptions, the nurse should implement the following intervention:
Notify the stroke team to assist with acute assessment and management. A stroke is a medical emergency that requires urgent intervention and specialized care. The stroke team is trained to quickly assess and manage stroke patients, including performing necessary diagnostic tests and initiating appropriate treatment. In this case, a STAT computerized tomography (CT) scan of the head has been ordered, indicating the need to evaluate the client's brain for possible ischemic or hemorrhagic stroke.
While keeping the bed in the lowest position and initiating seizure and fall precautions may be important considerations for stroke patients, notifying the stroke team takes precedence as they are specifically trained to manage acute stroke cases.
Administering aspirin to prevent further clot formation and platelet clumping is not appropriate without further assessment and confirmation of the type of stroke.
Additionally, testing for a swallowing reflex and performing communication deficit assessments can be important components of the overall stroke management plan, but they should be carried out by the stroke team or as directed by the healthcare provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bleeding gums are common during pregnancy due to hormonal changes that make gums more sensitive and prone to bleeding. This is not typically a sign of a serious condition and can usually be managed with good oral hygiene.
B. Faintness or lightheadedness upon rising is common in pregnancy due to blood pressure changes. This can often be managed with lifestyle modifications such as rising slowly, staying hydrated, and avoiding prolonged standing.
C. Swelling of the face during pregnancy can be an early sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage. This is a concerning symptom that requires immediate evaluation by a healthcare provider.
D. Urinary frequency is a common and usually benign symptom during pregnancy, especially in the first and third trimesters due to hormonal changes and pressure on the bladder. It does not typically require urgent reporting unless accompanied by other symptoms such as pain or burning during urination, which could indicate a urinary tract infection.
Correct Answer is D
Explanation
Incorrect. Rounding the edges of toenails can lead to ingrown toenails, which should be avoided.
B. Incorrect. Soaking feet twice daily can lead to dry skin and potentially increase the risk of infection, so it's not recommended.
C. Incorrect. Using moisturizing lotion between the toes can also increase the risk of moisture-related skin issues. It's better to keep the area between the toes dry.
D. Correct. Wearing clean cotton socks helps maintain proper foot hygiene and prevents moisture accumulation, reducing the risk of fungal infections.
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