A 78-year-old client is admitted to the Emergency Department with numbness and weakness of the right arm and slurred speech.
Which nursing intervention is a priority?

Prepare to administer recombinant tissue plasminogen activator (t-PA).

Assist with transport to a STAT non-contrast computed tomography scan of the head.

Perform a STAT EKG and assist with a STAT chest X-ray.

Notify the speech and language pathologist for a STAT dysphagia evaluation.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Administering recombinant tissue plasminogen activator (t-PA) may be necessary, but confirming ischemic stroke via CT scan precedes treatment to rule out hemorrhagic stroke, which contraindicates t-PA.

Choice B rationale

Performing a STAT non-contrast CT scan of the head is the priority to differentiate between ischemic and hemorrhagic stroke, enabling appropriate and timely intervention.

Choice C rationale

A STAT EKG and chest X-ray, though helpful in identifying concurrent cardiac or pulmonary issues, are not immediate priorities in acute stroke evaluation.

Choice D rationale

While assessing dysphagia is critical post-stroke, it is not a priority during initial stroke evaluation, which focuses on rapid imaging and differentiation of stroke type. .

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Correct Answer is B

Explanation

Choice A rationale

Administering oxygen at 6 liters per minute via nasal cannula risks hypercapnia in a client with emphysema due to impaired CO2 elimination. Oxygen should be titrated to maintain safe saturation levels, usually 88–92%.

Choice B rationale

Ipratropium is a bronchodilator that safely alleviates airway constriction in emphysema without systemic cardiovascular effects, making it suitable for a client with coronary artery disease and chronic obstructive pulmonary conditions.

Choice C rationale

Propranolol is contraindicated in emphysema due to its beta-blocking effects, which may exacerbate bronchoconstriction and reduce respiratory function, posing a significant risk to the client’s health.

Choice D rationale

Organic herbal supplements lack evidence-based safety and efficacy, especially in complex medical conditions like coronary artery disease and emphysema. They can also interact adversely with prescribed medications.

A. Increase a feeling of well-being in HIV+ patients. B. Help improve immune function. C. Maintain patient's strength and ability to care for oneself. D. Prevent transmission of the virus to others. E. Eliminate the virus from the body.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Proper nutrition, exercise, and stress reduction enhance psychological well-being, stimulating endorphin release, which improves mood and resilience, essential for managing chronic conditions like HIV.

Choice B rationale

These factors bolster immune function by reducing cortisol levels that impair immunity, supporting T-cell activity and promoting resistance against opportunistic infections common in HIV patients.

Choice C rationale

Maintaining strength and independence aids patients in daily functioning, reducing dependency and enhancing self-efficacy, which is critical for long-term adherence to therapeutic regimens in HIV.

Choice D rationale

Preventing virus transmission requires safe practices, not lifestyle changes alone. Nutrition and exercise cannot alter transmission mechanisms like exposure to body fluids.

Choice E rationale

Eliminating HIV completely necessitates antiretroviral therapy and advancements in medical science; lifestyle modifications alone are insufficient against viral integration within host DNA.

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A 78-year-old client is admitted to the Emergency Department with numbness and weakness of the right arm and slurred speech.Which nursing intervention is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a past medical history of coronary artery disease and emphysema.The nurse knows which agent is safest to give?

Correct Answer is B

Explanation

The nurse should educate clients who are HIV+ on proper nutrition, exercise, and stress reduction because these factors will: (Select All that Apply.)

Correct Answer is ["A","B","C"]

Explanation

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A 78-year-old client is admitted to the Emergency Department with numbness and weakness of the right arm and slurred speech.
Which nursing intervention is a priority?