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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Vigorous coughing or nose blowing increases pressure in the middle ear, potentially dislodging the stapes prosthesis, interfering with healing, and increasing risk of complications like vertigo or auditory damage.
Choice B rationale
Packing with dry dressing is contraindicated because it may trap moisture and increase infection risk. If drainage occurs, sterile measures are taken to assess and manage infection without creating ideal conditions for pathogens.
Choice C rationale
Irrigation of the ear canal risks introducing pathogens or disrupting the surgical area. Post-surgery, maintaining a dry environment helps reduce infection and promote proper healing.
Choice D rationale
Though bedrest may be recommended initially, prolonged immobility isn't essential unless specific complications arise. Movement minimizes risks of clot formation and encourages circulation, aiding recovery.
Correct Answer is B
Explanation
Choice A rationale
Nitroprusside is a vasodilator for hypertensive crises but is contraindicated in elevated ICP because it increases cerebral blood volume and exacerbates intracranial pressure, worsening the patient's condition.
Choice B rationale
Hypertonic saline (3%) helps reduce ICP by drawing excess fluid from brain tissue into the bloodstream through osmosis, effectively lowering intracranial pressure while maintaining cerebral perfusion.
Choice C rationale
Furosemide is a loop diuretic that reduces fluid overload but does not specifically target ICP. It is less effective in managing the osmotic balance required for intracranial pressure reduction.
Choice D rationale
Norepinephrine is a vasopressor used to treat hypotension and improve perfusion but does not lower ICP and may increase cerebral vasoconstriction, exacerbating intracranial hypertension. .
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