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 D

Explanation

Choice A rationale

Absence of short-term memory loss may be desirable but depends on the injury's severity and therapy progression. Memory recovery is inconsistent and often impractical as a definitive short-term outcome goal.

Choice B rationale

Resuming construction work is unrealistic within three weeks considering potential cognitive and physical impairments. This task exceeds achievable rehabilitation milestones, emphasizing safety over rapid return to demanding roles.

Choice C rationale

Pre-injury personality traits may not fully return, as emotional and personality changes often result from cerebral insults. Emotional stability is feasible but pre-injury personality restoration is speculative.

Choice D rationale

Medication adherence reflects successful cognitive rehabilitation, supporting long-term health stability by preventing further complications. This outcome is realistic and appropriate for patients recovering from intracranial injuries. .

A. Sharp, stabbing acute pain in the affected eye. B. Total loss of vision. C. A curtain-like loss of vision in the affected eye. D. Yellow discoloration of the sclera.

Correct Answer is C

Explanation

Choice A rationale

Detached retina typically does not present with sharp, stabbing pain. Instead, patients experience painless symptoms like vision abnormalities due to separation of the retina from supporting tissue.

Choice B rationale

Total vision loss is rare with a detached retina unless extensive damage occurs. Partial visual disruption, such as curtain-like vision loss, is a hallmark symptom.

Choice C rationale

A curtain-like loss of vision arises from retinal detachment, disrupting visual fields as the retina separates from its vascular supply and neural connections.

Choice D rationale

Yellow sclera discoloration is associated with jaundice due to bilirubin accumulation, unrelated to retinal detachment pathology, which affects visual symptoms and not scleral appearance.

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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?

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Correct Answer is C

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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?