A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?
Perform carotid massage.
Call for help.
Provide the client with water to test the gag reflex.
Administer thrombolytics.
The Correct Answer is B
Choice A reason: Performing carotid massage is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may worsen the condition or cause complications. Carotid massage is a technique that involves applying pressure to the carotid artery in the neck to stimulate the vagus nerve and slow down the heart rate. It is used to treat some types of arrhythmias, such as supraventricular tachycardia. However, carotid massage may dislodge a blood clot or plaque from the carotid artery and cause an embolic stroke, which is a type of ischemic stroke that occurs when a blood clot travels to the brain and blocks a blood vessel. Carotid massage may also cause bradycardia, hypotension, or syncope, which can reduce the blood flow to the brain and worsen the ischemic damage.
Choice B reason: Calling for help is an appropriate action for a nurse to take when a client has signs of a stroke, as it initiates the emergency response and allows for prompt evaluation and treatment. Stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. The sooner the stroke is recognized and treated, the better the chances of survival and recovery. Therefore, the nurse should call for help as soon as possible and activate the stroke protocol in the facility.
Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may cause aspiration or choking. A gag reflex is an involuntary contraction of the throat muscles that prevents foreign objects from entering the airway. It is tested by touching the back of the throat with a tongue depressor or a cotton swab. However, this test is not indicated in a client who has signs of a stroke, as it may trigger vomiting or coughing, which can increase intracranial pressure or cause bleeding. Moreover, giving water to a client who has signs of a stroke may be dangerous, as they may have dysphagia (difficulty swallowing) or facial weakness, which can impair their ability to swallow safely and increase the risk of aspiration pneumonia.
Choice D reason: Administering thrombolytics is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may be contraindicated or harmful depending on the type and timing of the stroke. Thrombolytics are medications that dissolve blood clots and restore blood flow. They are used to treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, thrombolytics are not effective for hemorrhagic stroke, which is caused by bleeding into or around the brain. In fact, thrombolytics may worsen hemorrhagic stroke by increasing bleeding and intracranial pressure. Therefore, thrombolytics should only be given after confirming the type of stroke by imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Thrombolytics should also be given within a specific time window after the onset of symptoms, usually within 3 to 4.5 hours, as they may lose their effectiveness or cause complications if given too late. Therefore, administering thrombolytics is not an action that a nurse can take without proper assessment and orders from the health care provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Mitral valve disease is not a disorder that makes clients especially vulnerable to ozone effects, as it does not affect the respiratory system. Mitral valve disease is a condition that affects the mitral valve, which is the valve that separates the left atrium and the left ventricle of the heart. Mitral valve disease can cause the valve to become narrow (stenosis) or leaky (regurgitation), affecting the blood flow and oxygen delivery to the body. Mitral valve disease can cause symptoms such as shortness of breath, fatigue, chest pain, palpitations, and swelling of the legs.
Choice B reason: Asthma is a disorder that makes clients especially vulnerable to ozone effects, as it affects the respiratory system. Asthma is a chronic inflammatory condition that causes the airways to become narrow, swollen, and sensitive to triggers such as allergens, irritants, infections, or exercise. Asthma can cause symptoms such as wheezing, coughing, chest tightness, and difficulty breathing. Ozone is a gas that is formed when sunlight reacts with pollutants in the air. Ozone can irritate the lungs and worsen asthma symptoms by causing inflammation, bronchoconstriction, and mucus production. Ozone can also reduce lung function and increase the risk of respiratory infections.
Choice C reason: Nasal polyps are not a disorder that makes clients especially vulnerable to ozone effects, as they do not affect the respiratory system. Nasal polyps are benign growths that form in the lining of the nose or sinuses. Nasal polyps can cause symptoms such as nasal congestion, runny nose, postnasal drip, loss of smell or taste, headache, and snoring. Nasal polyps are usually associated with chronic inflammation or allergies, but their exact cause is unknown.
Choice D reason: Seasonal allergies are not a disorder that makes clients especially vulnerable to ozone effects, as they do not affect the respiratory system. Seasonal allergies are allergic reactions that occur during certain times of the year when pollen or mold spores are high in the air. Seasonal allergies can cause symptoms such as sneezing, itching, watery eyes, runny nose, and sore throat. Seasonal allergies are caused by an overreaction of the immune system to harmless substances in the environment.
Correct Answer is B
Explanation
Choice A reason: Giving care with a focus on the aggregate's needs is not the best description of client-focused community-based nursing, as it implies that the nurse is providing care to a population or a group of individuals who share some common characteristics or risk factors. This is more aligned with the concept of population-focused community-based nursing, which aims to improve the health outcomes of a defined group of people.
Choice B reason: A philosophy that guides family-centered illness care is the best description of client-focused community-based nursing, as it reflects the core values and principles of this approach. Client-focused community-based nursing is a model of care that emphasizes the individual and family as the unit of care, rather than the disease or the health problem. It involves collaborating with the client and family to identify their needs, preferences, strengths, and resources, and providing holistic, culturally sensitive, and evidence-based care that promotes health, wellness, and quality of life.
Choice C reason: Providing care with a focus on the group's needs is not the best description of client-focused community-based nursing, as it suggests that the nurse is providing care to a collective or a social unit that shares some common goals or interests. This is more aligned with the concept of community-oriented community-based nursing, which aims to improve the health status of a specific community or subpopulation.
Choice D reason: A value system in which all clients receive optimal care is not the best description of client-focused community-based nursing, as it does not capture the essence or uniqueness of this approach. While it is true that client-focused community-based nursing strives to provide high-quality care to all clients, it also recognizes that each client and family has different needs, preferences, and expectations that require individualized and tailored interventions.
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