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 C

Explanation

Choice A rationale

The latent period of HIV includes asymptomatic phases when the CD4+ count remains above 200 cells/mm. Pneumocystic pneumonia and low CD4+ counts signify progression beyond latent HIV.

Choice B rationale

HIV-positive status reflects infection presence, but it does not confirm AIDS unless CD4+ count drops below 200 cells/mm and opportunistic infections occur, such as pneumocystic pneumonia.

Choice C rationale

AIDS is diagnosed when CD4+ count decreases below 200 cells/mm, coupled with opportunistic infections. Pneumocystic pneumonia indicates a weakened immune system due to advanced disease.

Choice D rationale

Seroconversion marks the initial immune response to HIV infection with detectable antibodies but occurs before CD4+ counts decline significantly and opportunistic infections appear.

A. Can squeeze the nurse's hand upon verbal request. B. Follows simple commands with repetition/prompting from nurse. C. Has purposeful movement when the nurse rubs the sternum. D. Extends upper and lower extremities in response to painful stimuli.

Correct Answer is D

Explanation

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

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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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Naxlex Comprehensive Predictor Exams

A client, who has tested positive for human immunodeficiency virus (HIV), now presents with a CD4+ count of less than 200 cells/mm and pneumocystic pneumonia.A normal range for a CD4+ count is 500-1500 cells/mm.How would the nurse evaluate these findings? The client:

Correct Answer is C

Explanation

The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.In the morning assessment, the patient opened his eyes in response to noxious stimuli.Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

Correct Answer is D

Explanation

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

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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?