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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Canned chicken broth with barley is not the best choice for a patient with hypertension. Canned foods, including chicken broth, are often high in sodium, which can raise blood pressure.
Choice B rationale
Tomato juice and gluten-free crackers may seem like a healthy option, but tomato juice can be high in sodium. While gluten-free crackers can be part of a healthy diet, they don’t offer any specific benefits for controlling hypertension.
Choice C rationale
A plain baked sweet potato is an excellent choice for a patient with hypertension. Sweet potatoes are high in potassium, which can help lower blood pressure. They’re also a good source of fiber and are naturally low in sodium.
Choice D rationale
Dill pickles and black olives are both high in sodium, which can raise blood pressure. Therefore, they’re not a good choice for someone with hypertension.
Correct Answer is C
Explanation
Choice C rationale
In a hurricane disaster medical area, drinking water contaminated by sewage is a common source of contamination that could lead to diarrhea. Hurricanes and severe storms often result in flooding, which can contaminate drinking water supplies with sewage and other pollutants. This can lead to the spread of waterborne diseases, including those that cause diarrhea. Type 2 diabetes Explore
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