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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Allogeneic Transplant

Matched Donor: This refers to a donor who is not genetically identical to the recipient but has a similar tissue type. This can include unrelated donors who are matched through registries.

Sibling Donor: A sibling can be a potential donor if they have a matching tissue type. Since siblings share genes, there is a higher chance of finding a match.

Autologous Transplant

Self-Donor: In this type of transplant, the patient donates their own stem cells before undergoing treatment (such as chemotherapy or radiation). These cells are then stored and re-infused after treatment to help the body recover.

Syngeneic Transplant

Twin Donor: This involves a donor who is an identical twin. Since identical twins have the same genetic makeup, there is a perfect match, reducing the risk of graft-versus-host disease (GVHD).

A. ask simple yes or no questions. B. develop a list of simple words that the client can read and practice saying. C. track the amount of time the client uses to speak. D. change the subject if the client does not respond in a timely manner.

Correct Answer is A

Explanation

A. Asking yes or no questions can help facilitate communication, as they require less verbal output from the client and can help the nurse understand the client’s needs or thoughts without overwhelming them
B. This option is somewhat useful, as practicing words can help the client regain some verbal skills. However, it may not be the most effective immediate intervention. Clients with expressive aphasia often struggle to produce speech rather than understand it, and they may not benefit as much from this approach without additional support from speech therapy.
C. This intervention is not beneficial for improving communication. Tracking time spent speaking could create additional pressure on the client and may contribute to frustration rather than facilitate communication. It does not address the underlying issue of expressive aphasia.
D. This is not an appropriate intervention. Changing the subject can confuse or frustrate the client further, making it more difficult for them to communicate. It does not support their efforts to express themselves and may discourage them from trying to communicate altogether.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Match the type of bone marrow transplant to the appropriate donor. The nurse is caring for a client who was diagnosed with Acute Myelogenous Leukemia (AML). The client is in need of a bone marrow transplant. Match the type of bone marrow transplant to the appropriate donor:

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

The nurse identifies the client problem of Impaired Verbal Communication for a client following a stroke who exhibits expressive aphasia. An appropriate nursing intervention to help the client to communicate is to:

Correct Answer is A

Explanation

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