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 A
Explanation
A. Correct. Informed consent means the client has the right to refuse treatment even after giving initial consent. The nurse should respect the client's autonomy and decision.
B. Incorrect. This statement does not respect the client's right to make decisions about her treatment.
C. Incorrect. While this statement might be true for some individuals, it does not address the client's current hesitation and does not respect her autonomy.
D. Incorrect. This statement does not address the client's expressed hesitation about the treatment.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
Anticipated actions for the client include:
- A. Administer nifedipine.
- B. Assess blood pressure every 15 minutes.
- D. Assess for urinary retention.
Contraindicated actions for the client include:
- C. Perform suctioning (since there is no indication or information suggesting the need for suctioning).
- E. Place client in supine position (as it might worsen the symptoms).
- F. Withhold pain medication for headache until other manifestations resolve (it's important to address the headache promptly, especially if acetaminophen is prescribed for pain relief).
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