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 C
Explanation
Jaw pain in a client taking alendronate, a bisphosphonate, for postmenopausal osteoporosis may be a sign of a rare but serious side effect called osteonecrosis of the jaw (ONJ). Therefore, the nurse should respond by: Report the client's jaw pain to the healthcare provider.
Jaw pain can be an indication of ONJ, a condition characterized by the death of jawbone tissue. It is important to notify the healthcare provider so that further evaluation and appropriate management can be initiated. The healthcare provider will determine the best course of action, which may include referral to a specialist for further assessment and treatment.
Determining how the client is administering the medication is not the immediate concern in this situation. While it is important to ensure that the client is following proper administration instructions for alendronate, addressing the jaw pain takes precedence. Advising the client to gargle with warm salt water twice daily may not be sufficient or appropriate for managing jaw pain related to alendronate use. The client needs a comprehensive assessment by the healthcare provider to determine the cause of the jaw pain and provide appropriate interventions.
Confirming that jaw pain is a common symptom of osteoporosis is not accurate. While osteoporosis can lead to bone pain, jaw pain specifically associated with bisphosphonate use is more likely to be related to ONJ and requires further evaluation and management.
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