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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Intracranial hemorrhage: Given the client's history of falling out of bed, subsequent head injury, headache, seizure, and neurological deterioration (weakness on the right side of the body, dilated right pupil, confusion), there is a significant concern for intracranial hemorrhage. These symptoms suggest possible bleeding within the skull, which can rapidly escalate and become life-threatening.

Heart rate: The client's decreasing heart rate from 70/min at 1230 to 40/min at 1430 indicates bradycardia, which can be a critical sign of increased intracranial pressure (ICP) due to intracranial hemorrhage. Bradycardia is a late sign of increased ICP and indicates severe neurological compromise. In this context, the irregular heart rate and the associated neurological symptoms raise concerns for impending or ongoing intracranial hemorrhage.

A. Apply an eye patch to the right eye. B. Teach the patient that the left visual deficit will resolve. C. Approach the patient from the right side. D. Place needed objects on the patient's left side.

Correct Answer is D

Explanation

A. Apply an eye patch to the right eye: Applying an eye patch to the right eye would further limit the patient's visual field, exacerbating the homonymous hemianopsia. This intervention is not appropriate for managing hemianopsia.

B. Teach the patient that the left visual deficit will resolve: Homonymous hemianopsia typically results from damage to the visual pathway in the brain and may not resolve completely. While visual rehabilitation techniques may help improve compensatory strategies, it is important to acknowledge and address the permanent nature of the deficit.

C. Approach the patient from the right side: Approaching the patient from the right side may startle them and increase the risk of falls or accidents due to the inability to perceive objects on their left side. The nurse should approach the patient from the unaffected side (the left side) to minimize the risk of injury.

D. Place needed objects on the patient's left side: Placing needed objects on the patient's left side helps compensate for the visual deficit by ensuring that essential items are within the patient's field of vision. This intervention promotes independence and safety for the patient with homonymous hemianopsia.

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A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client on a medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdown as evidenced by the client's dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?

Correct Answer is D

Explanation

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