A 78-year-old client is admitted to the Emergency Department (ED) with numbness and weakness of the right arm and slurred speech. Which nursing intervention is a priority?
Discuss the precipitating factors that caused the symptoms
Schedule a STAT computed tomography (CT) scan of the head
Prepare to administer recombinant tissue plasminogen activator (t-PA)
Notify the Speech Pathologist for an emergency consult
The Correct Answer is B
A. While it's important to gather information about the client's symptoms, the priority in this situation is to determine the underlying cause of the neurological symptoms. A CT scan can quickly identify if there's been a stroke or other brain injury.
B. This is the most appropriate and urgent intervention. A CT scan can rapidly identify if the client has had a stroke, which is a time-sensitive medical emergency. Early diagnosis and treatment are crucial for minimizing brain damage and improving outcomes.
C. t-PA is a medication used to dissolve blood clots in the brain, but it is only effective if given within a specific time window after the onset of stroke symptoms. Without a confirmed diagnosis of stroke from a CT scan, administering t-PA could be harmful.
D. While a speech pathologist may be involved in the client's care later on, the priority is to determine the underlying cause of the neurological symptoms and initiate appropriate treatment. A CT scan is essential for this purpose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["14"]
Explanation
154 lbs ÷ 2.2 lbs/kg = 70 kg
20 units/kg * 70 kg = 1400 units
1400 units ÷ 25,000 units/250 mL = 14 mL
Therefore, the nurse will administer 14 mL of Heparin.
Correct Answer is B
Explanation
A. CA-125 is primarily associated with ovarian cancer and is not a relevant tumor marker for testicular cancer. Serum ceruloplasmin is a copper-carrying protein that can be elevated in various conditions, but it is not specific for testicular cancer. Therefore, this option is not appropriate.
B. Both hCG and AFP are tumor markers specifically associated with testicular cancer. Elevated levels of these markers can indicate the presence of non-seminomatous testicular tumors. Monitoring these markers is essential for diagnosis, assessing treatment response, and detecting recurrence.
C. EPO is involved in red blood cell production and is not a tumor marker for testicular cancer. CEA is primarily associated with colorectal cancer and some other malignancies, but it is not specific for testicular cancer.
D. PSA is a tumor marker associated with prostate cancer, not testicular cancer. While hCG is relevant for testicular cancer, the inclusion of PSA makes this option inappropriate for a client with testicular cancer.
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