The nurse notes that a client has ataxia. Which test does the nurse use to gain more information about this client's gait?

Choice A reason: Performing carotid massage is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may worsen the condition or cause complications. Carotid massage is a technique that involves applying pressure to the carotid artery in the neck to stimulate the vagus nerve and slow down the heart rate. It is used to treat some types of arrhythmias, such as supraventricular tachycardia. However, carotid massage may dislodge a blood clot or plaque from the carotid artery and cause an embolic stroke, which is a type of ischemic stroke that occurs when a blood clot travels to the brain and blocks a blood vessel. Carotid massage may also cause bradycardia, hypotension, or syncope, which can reduce the blood flow to the brain and worsen the ischemic damage.

Choice B reason: Calling for help is an appropriate action for a nurse to take when a client has signs of a stroke, as it initiates the emergency response and allows for prompt evaluation and treatment. Stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. The sooner the stroke is recognized and treated, the better the chances of survival and recovery. Therefore, the nurse should call for help as soon as possible and activate the stroke protocol in the facility.

Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may cause aspiration or choking. A gag reflex is an involuntary contraction of the throat muscles that prevents foreign objects from entering the airway. It is tested by touching the back of the throat with a tongue depressor or a cotton swab. However, this test is not indicated in a client who has signs of a stroke, as it may trigger vomiting or coughing, which can increase intracranial pressure or cause bleeding. Moreover, giving water to a client who has signs of a stroke may be dangerous, as they may have dysphagia (difficulty swallowing) or facial weakness, which can impair their ability to swallow safely and increase the risk of aspiration pneumonia.

Choice D reason: Administering thrombolytics is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may be contraindicated or harmful depending on the type and timing of the stroke. Thrombolytics are medications that dissolve blood clots and restore blood flow. They are used to treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, thrombolytics are not effective for hemorrhagic stroke, which is caused by bleeding into or around the brain. In fact, thrombolytics may worsen hemorrhagic stroke by increasing bleeding and intracranial pressure. Therefore, thrombolytics should only be given after confirming the type of stroke by imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Thrombolytics should also be given within a specific time window after the onset of symptoms, usually within 3 to 4.5 hours, as they may lose their effectiveness or cause complications if given too late. Therefore, administering thrombolytics is not an action that a nurse can take without proper assessment and orders from the health care provider.

Choice A reason: The inability to take risks is not a quality of an effective nurse leader, as it may limit the leader's potential for growth, innovation, and improvement. Effective nurse leaders are willing to take calculated risks that are based on evidence, experience, and intuition. They are also able to learn from their mistakes and failures and use them as opportunities for development.

Choice B reason: Never consider being a follower is not a quality of an effective nurse leader, as it may indicate a lack of flexibility, collaboration, and respect for others. Effective nurse leaders are able to adapt to different situations and roles, depending on the needs and goals of the team. They are also able to recognize the strengths and contributions of their followers and empower them to achieve their full potential.

Choice C reason: The ability to set priorities is a quality of an effective nurse leader, as it helps the leader to focus on the most important and urgent tasks and goals. Effective nurse leaders are able to identify the needs and expectations of their clients, staff, and organization, and allocate their time, resources, and energy accordingly. They are also able to delegate tasks appropriately and efficiently.

Choice D reason: Integrity is a quality of an effective nurse leader, as it reflects the leader's honesty, trustworthiness, and ethical standards. Effective nurse leaders are able to act in accordance with their values and principles, and uphold the professional code of conduct. They are also able to communicate openly and transparently, and accept responsibility and accountability for their actions and decisions.

Choice E reason: Critical care certification is not a quality of an effective nurse leader, as it is not a requirement or a guarantee for leadership success. Critical care certification is a credential that demonstrates the nurse's knowledge and competence in providing care to critically ill patients. While it may enhance the nurse's clinical skills and confidence, it does not necessarily reflect the nurse's leadership skills or abilities. Effective nurse leaders can come from various backgrounds and specialties, as long as they have the necessary qualities and attributes that enable them to lead others effectively.