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 B

Explanation

A. While antibiotics may be necessary if a UTI is confirmed, requesting a prescription would not be the immediate nursing action. The nurse must first assess the situation thoroughly and obtain necessary diagnostic information before medications can be prescribed.
B. This option is the most appropriate immediate action. Obtaining a full set of vital signs helps assess
the client’s overall condition, including the degree of fever and any signs of systemic infection. Collecting

a urine specimen will facilitate further evaluation, such as a urinalysis and culture, to confirm a UTI and identify the appropriate antibiotic treatment.
C. While increasing fluid intake can help with urinary tract health and dilute the urine, it is not an immediate priority in this situation. The client may need more urgent assessment and possible medical intervention rather than just dietary changes.
D. Although protective isolation may be warranted given the client’s immunocompromised state due to chemotherapy and radiation, it is not the immediate priority based on the current symptoms. The focus should first be on assessing and addressing the potential UTI.

A. Limit fluids with meals B. Void frequently C. Follow up with a prostate specific antigen D. Avoid decaffeinated drinks

Correct Answer is B

Explanation

A. Limiting fluids with meals is not a recommended practice for preventing prostatitis. Staying hydrated is generally encouraged to promote urinary health. This option does not address the prevention of prostatitis recurrence.
B. This is a good instruction. Frequent voiding helps reduce the risk of urinary stasis and potential bacterial growth in the urinary tract, which can contribute to prostatitis. Encouraging the client to empty their bladder regularly is beneficial in preventing recurrence.
C. While monitoring PSA levels can be important for assessing prostate health, it is not a direct preventive measure for prostatitis recurrence. PSA tests are primarily used to screen for prostate cancer or monitor prostate conditions rather than prevent prostatitis itself.
D. This recommendation is not appropriate for preventing prostatitis. While caffeine may irritate the bladder and prostate, decaffeinated drinks typically do not have the same effect and can be a good source of hydration. Avoiding decaffeinated drinks does not contribute to prostatitis prevention.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

To prevent the reoccurrence of prostatitis, the nurse should provide the client with which discharge instruction?

Correct Answer is B

Explanation

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