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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Being suspicious of others is more characteristic of paranoid personality disorder.
B. Incorrect. Ritualistic behavior is more characteristic of obsessive-compulsive personality disorder.
C. Correct. Preoccupation with aging and a fear of losing their physical attractiveness or power is a common trait in individuals with narcissistic personality disorder.
D. Incorrect. Exhibiting separation anxiety is not a defining characteristic of narcissistic personality disorder.
Correct Answer is D
Explanation
A. Incorrect. Releasing the tourniquet is a step that can be taken after advancing the catheter into the vein.
B. Incorrect. Retracting the stylet at this point could disrupt the position of the catheter and cause leakage or damage.
C. Incorrect. Flushing the catheter with saline is an appropriate step after ensuring the catheter is correctly placed in the vein.
D. Correct. After noting a blood return in the flashback chamber, the next step is to advance the catheter into the vein to ensure proper placement for intravenous access.
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