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 D
Explanation
A. Incorrect. Mild swelling under the sutures is a common finding after surgery and may not necessarily require reporting unless it worsens or is associated with other concerning symptoms.
B. Incorrect. Pink-tinged coloration can be a normal part of the healing process, as long as there is no excessive redness, warmth, or signs of infection.
C. Incorrect. Crusting of exudate on the incisional line can occur during the healing process and may not necessarily indicate a problem unless it's accompanied by signs of infection.
D. Correct. Partial separation of the upper part of the incisional line can indicate wound dehiscence, a potential complication that requires immediate attention to prevent infection and further complications.
Correct Answer is D
Explanation
A. Opioid medications can cause constipation, and increasing fluid intake helps prevent dehydration and promotes bowel regularity. However, it does not directly prevent cosntipation.
B. Incorrect. While some laxatives or stool softeners might be recommended, mineral oil is generally not recommended due to its potential to interfere with the absorption of fat-soluble vitamins.
C. Incorrect. Increasing insoluble fiber intake, rather than decreasing it, can help prevent constipation.
D. Increasing exercise is key in preventing constipation caused by opiod analgesics
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