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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","D","F"]

Explanation

Choice A rationale

Assisting the client to the bathroom is appropriate as clonazepam can cause dizziness and unsteadiness, increasing the risk of falls.

Choice B rationale

Having an opioid agonist at the bedside is not necessary for a client starting clonazepam. Clonazepam is a benzodiazepine, not an opioid.

Choice C rationale

Providing oral care at least twice a day is generally good practice for all patients, but it’s not specifically related to clonazepam use.

Choice D rationale

Assessing mental status regularly is crucial as clonazepam can cause changes in mood and behavior.

Choice E rationale

Monitoring calcium levels is not typically required for a client starting clonazepam.

Choice F rationale

Screening for orthostatic hypotension is important as clonazepam can lower blood pressure, leading to dizziness and fainting when the client stands up.

A. Check capillary refill on bilateral upper extremities. B. Administer ondansetron 4 mg IV. C. Inspect the bandage for drainage.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

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Naxlex Comprehensive Predictor Exams

What nursing interventions are appropriate for a client starting clonazepam? Select all that apply.

Correct Answer is ["A","D","F"]

Explanation

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

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