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: Mitigation is not the correct level of the National Response Framework, as it refers to the actions taken to reduce or eliminate the long-term risk to human life and property from natural or man-made hazards. Mitigation activities include implementing building codes, zoning ordinances, land use planning, and flood insurance programs. Mitigation is a continuous process that occurs before, during, and after a disaster.

Choice B reason: Security is not the correct level of the National Response Framework, as it refers to the actions taken to protect the nation from threats or attacks by terrorists, criminals, or hostile states. Security activities include conducting intelligence operations, screening travelers and cargo, enforcing laws and regulations, and preventing cyberattacks. Security is a shared responsibility among federal, state, local, tribal, territorial, and private sector partners.

Choice C reason: Preparedness is the correct level of the National Response Framework, as it refers to the actions taken to plan, organize, equip, train, and exercise to build and sustain the capabilities necessary to prevent, protect against, mitigate the effects of, respond to, and recover from those threats that pose the greatest risk. Preparedness activities include developing emergency plans, conducting drills and exercises, educating the public, and establishing partnerships and coordination mechanisms. Preparedness is a continuous cycle of improvement that involves assessing needs, setting goals, implementing plans, and evaluating outcomes.

Choice D reason: The response phase is not the correct level of the National Response Framework, as it refers to the actions taken to save lives, protect property and the environment, stabilize the situation, and meet basic human needs in the immediate aftermath of a disaster. Response activities include activating emergency operations centers, deploying resources and personnel, providing mass care and sheltering, restoring critical infrastructure and services, and conducting search and rescue operations. Response is a short-term process that aims to restore normalcy as soon as possible.