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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The patient’s history indicates that she had difficulty breathing during a hike. This event led her to the emergency department. Difficulty breathing during physical activity such as hiking can be a symptom of an asthma exacerbation.

Choice B rationale

While severe allergic reactions can cause difficulty breathing, the patient’s history does not indicate that she experienced an allergic reaction prior to her emergency department visit.

Choice C rationale

Panic attacks can cause symptoms such as rapid heart rate, sweating, and shortness of breath. However, the patient’s history does not indicate that she had a panic attack prior to her emergency department visit.

Choice D rationale

Fainting, or loss of consciousness, can be caused by various conditions, including dehydration, low blood sugar, and heart problems. However, the patient’s history does not indicate that she fainted prior to her emergency department visit.

A. Total blood loss of 800 mL B. Fundus massaged until firm and at umbilicus C. Multiple large clots were expelled D. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air .

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

Explanation

The findings suggest that the client’s condition has improved.

Choice A rationale

A total blood loss of 800 mL is a significant amount, but it is within the normal range for blood loss during and after childbirth. Therefore, this does not necessarily put the client at risk for hypovolemia.

Choice B rationale

A fundus that is firm and at the level of the umbilicus indicates that the uterus is contracting properly after childbirth, which helps to prevent excessive bleeding.

Choice C rationale

The expulsion of multiple large clots could indicate that the body is effectively clotting blood, which can prevent excessive bleeding.

Choice D rationale

A blood pressure of 110/80 mm Hg, a heart rate of 66 beats/minute, and an oxygen saturation of 98% on room air are all within normal ranges, indicating that the client is stable and not at risk for hypovolemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A straight catheter produced 500 mL of clear yellow urine. For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

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

Explanation

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

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