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 B
Explanation
Choice A rationale:
Storing unused patches in the refrigerator is not necessary for transdermal scopolamine patches. Refrigeration is not a requirement for their storage.
Choice B rationale:
Applying the patch prior to traveling is the correct choice. Transdermal scopolamine patches are used to prevent motion sickness. Applying the patch before the journey allows the medication to be absorbed before exposure to motion, ensuring its effectiveness during travel.
Choice C rationale:
Placing the patch on the upper arm is a specific and correct instruction for applying transdermal scopolamine patches. The patch should be placed on a clean, dry, and hairless area of the skin, preferably behind the ear or on the upper arm.
Choice D rationale:
Replacing a dislodged patch onto the same location is incorrect. If the patch becomes dislodged, it should be replaced with a new patch on a different, clean, and dry area of the skin. Reapplying a dislodged patch to the same spot may result in uneven absorption and reduced effectiveness.
Correct Answer is ["A","C","D","G"]
Explanation
A. "Try using an abdominal support belt." - An abdominal support belt is recommended to provide support to the growing abdomen and can help alleviate backaches that are common during pregnancy.
B. "Take hot showers to help relieve itching." - This statement is incorrect. Hot showers can actually worsen itching and dry out the skin. Lukewarm showers are recommended instead.
C. "Wear loose-fitting clothing." - This statement is correct. Loose-fitting clothing can provide comfort and reduce irritation, especially in areas experiencing itching.
D. "Wear flat or low-heeled shoes." - This statement is correct. Flat or low-heeled shoes provide better support and stability during pregnancy, reducing the risk of falls.
E. "You can douche twice weekly." - This statement is incorrect. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infections.
F. "Eat two large meals a day." - This statement is incorrect. Eating large meals can lead to discomfort and heartburn. It is better to eat frequent smaller meals throughout the day during pregnancy.
G. "You should avoid fried foods." - This statement is correct. Fried foods can exacerbate heartburn and should be avoided to reduce discomfort.
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