A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
Send the patient for a computed tomography (CT) scan.
Check the respiratory rate and effort.
Assess the Glasgow Coma Scale score.
Take the patient's blood pressure.
The Correct Answer is B
A. Send the patient for a computed tomography (CT) scan: While obtaining a CT scan is important for diagnosing potential causes of the patient's left-sided hemiparesis, assessing the patient's respiratory status takes precedence to ensure adequate oxygenation and ventilation.
B. Check the respiratory rate and effort: Assessing the patient's respiratory rate and effort is the first priority to identify any signs of respiratory distress or compromise. Adequate oxygenation and ventilation are essential for maintaining vital organ function.
C. Assess the Glasgow Coma Scale score: While assessing the Glasgow Coma Scale score is important for evaluating the patient's level of consciousness and neurological status, it is not the first action to take in a patient with potential respiratory compromise.
D. Take the patient's blood pressure: While obtaining the patient's blood pressure is important for assessing hemodynamic stability, it is not the first priority when the patient presents with left-sided hemiparesis and may be at risk for respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assess for the presence of chest pain: While chest pain should always be assessed in a comprehensive health history and physical examination, it is not specifically related to multiple sclerosis unless there are concurrent cardiac issues.
B. Inquire about urinary tract problems: Urinary symptoms such as urinary urgency, frequency, hesitancy, or incontinence are common in multiple sclerosis due to neurogenic bladder dysfunction. Therefore, it is essential to inquire about these symptoms to assess the extent of neurological involvement and provide appropriate management.
C. Inspect the skin for rashes or discoloration: While skin manifestations can occur in multiple sclerosis, they are less common and not typically primary concerns during initial assessment. However, if the patient reports skin changes, they should be evaluated accordingly.
D. Ask the patient about any increase in libido: Changes in libido are not typically associated with multiple sclerosis unless they are related to psychological or emotional factors. While sexual dysfunction can occur in MS, it is not the primary focus during the initial assessment unless the patient presents with related concerns.
Correct Answer is B
Explanation
A. Oral Levetiracetam: Oral medications are not appropriate for immediate seizure management during an active seizure. Intravenous medications are typically used for acute seizure management.
B. IV Lorazepam: Lorazepam is a benzodiazepine that is commonly used as a first-line medication for terminating acute seizures. It acts quickly to suppress seizure activity and is often administered intravenously during a seizure episode.
C. IV Ondansetron: Ondansetron is an antiemetic medication used to prevent nausea and vomiting and is not indicated for seizure management.
D. Magnesium Sulfate: Magnesium sulfate is not typically used for seizure management in the acute setting. It may be used for certain types of seizures or as a treatment for eclampsia, but it is not a first-line medication for acute seizure termination.
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