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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A rising systolic blood pressure: While increased intracranial pressure can lead to changes in blood pressure, it is not typically the first sign observed. Changes in blood pressure may occur later in the progression of increased intracranial pressure.
B. Change in mood or attention level: Changes in mood, behavior, or level of consciousness are often early signs of increased intracranial pressure. These changes may include irritability, confusion, restlessness, or lethargy.
C. Irregular respiratory rate and depth: Respiratory changes such as irregular breathing patterns or Cheyne-Stokes respirations can occur with increased intracranial pressure, but they are not typically the first sign observed.
D. A bounding radial pulse: While changes in pulse rate or quality may occur with increased
intracranial pressure, a bounding radial pulse is not typically the first sign observed. It may occur later in the progression of increased intracranial pressure as compensation mechanisms fail.
Correct Answer is A
Explanation
A. Paraplegia: Paraplegia is the paralysis of the lower extremities and possibly the trunk, which can occur with a spinal cord injury at the level of the T2-T3 vertebrae.
B. Paresthesia: Paresthesia refers to abnormal sensations such as tingling or numbness and is not typically associated with a spinal cord injury at the T2-T3 level. It may occur with nerve damage but is not the primary disability anticipated in this scenario.
C. Quadriplegia: Quadriplegia, also known as tetraplegia, involves paralysis of all four limbs and the trunk. It is more commonly associated with injuries at higher levels of the spinal cord, such as cervical injuries.
D. Hemiplegia: Hemiplegia involves paralysis of one side of the body and is typically caused by a stroke or brain injury, not a spinal cord injury at the T2-T3 level.
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