The nurse is caring for a patient 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 patient, including a STAT computerized tomography scan of the head.
What intervention should the nurse perform in the immediate management of the patient?
Initiate bilateral intermittent sequential pneumatic compression devices.
Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
Maintain elevated positioning of the dependent joints on affected side.
Obtain a focused history to determine recent bleeding and use of anticoagulants.
The Correct Answer is B
Choice A rationale
Initiating bilateral intermittent sequential pneumatic compression devices is not the most appropriate immediate intervention for a patient showing signs of a possible stroke. These devices are typically used to prevent deep vein thrombosis in patients who are immobile, not for stroke management.
Choice B rationale
Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is the correct intervention. This position can help reduce intracranial pressure and facilitate venous drainage. In the case of a suspected stroke, it’s crucial to maintain proper cerebral blood flow.
Choice C rationale
Maintaining elevated positioning of the dependent joints on the affected side is not the immediate priority in stroke management. While it’s important to prevent contractures and maintain functional positioning, the immediate concern is to stabilize the patient’s condition.
Choice D rationale
Obtaining a focused history to determine recent bleeding and use of anticoagulants is important, but it’s not the first intervention. While this information will be necessary for the healthcare provider to determine the appropriate course of treatment, the immediate priority is to manage the patient’s acute symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
The assessment findings that require immediate follow up by the nurse are: The client has mild subcostal retractions. This could indicate that she is using accessory muscles to breathe, which is a sign of respiratory distress. The client is sitting in an upright position. This is a common position for people who are having difficulty breathing because it allows for maximum expansion of the lungs. Wheezes are noted throughout the lung fields. Wheezing can be a sign of an obstructive process such as asthma. The client is pale. Paleness can be a sign of decreased oxygenation. Her heart rate is 122 beats/minute, which is above the normal range and can indicate that her body is working harder to get oxygen. Her oxygen saturation is 91% on room air. Normal oxygen saturation is generally 95% or higher, so this could indicate that she is not getting enough oxygen.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
- I should have taken some allergy medications before going on the hike.- Understanding: Allergens can trigger asthma symptoms, and taking allergy medication can help prevent an asthma attack.
- I have been very stressed out lately and should work on stress management.- Understanding: Stress can exacerbate asthma symptoms. Managing stress effectively can help control asthma.
- I should have taken an extra dose of fluticasone-salmeterol.- No Understanding: Medication dosage should be as prescribed by the healthcare provider. Taking an extra dose without medical advice can lead to side effects and is not necessarily effective in preventing an asthma attack.
- I should have eaten a snack halfway through the hike.- No Understanding: While maintaining good nutrition is important for overall health, eating a snack specifically during a hike is not directly related to preventing an asthma attack.
- My friend smoked cigarettes during the hike.- Understanding: Secondhand smoke is a common trigger for asthma. Avoiding exposure to cigarette smoke can help prevent asthma symptoms.
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