A nurse is caring for a client scheduled for a functional assessment who asks, “What is the purpose of this assessment?” How should the nurse most appropriately respond to the client?

Choice A reason:

Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.

Choice B reason:

Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.

Choice C reason:

Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.

Choice D reason:

Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.

Choice A reason:

Assisting the client with active range of motion exercises is important for preventing complications such as contractures and maintaining mobility. However, it is not the priority intervention in the acute phase of a hemorrhagic stroke. The primary focus should be on stabilizing the client and monitoring their condition closely.

Choice B reason:

Maintaining strict bed rest to minimize cerebral blood flow is not appropriate for managing a hemorrhagic stroke. While bed rest may be necessary to prevent further injury, the priority is to monitor the client’s neurological status and vital signs to detect any changes that may indicate worsening of the condition.

Choice C reason:

Monitoring vital signs and neurological status frequently is the priority intervention for a client who has experienced a hemorrhagic stroke. Close monitoring allows the nurse to detect any changes in the client’s condition promptly and take appropriate action. This is crucial for preventing complications and ensuring timely intervention if the client’s condition deteriorates.

Choice D reason:

Administering anticoagulant medications is contraindicated in hemorrhagic stroke because they can exacerbate bleeding. Anticoagulants are used in ischemic stroke to prevent clot formation, but in hemorrhagic stroke, the focus is on controlling bleeding and stabilizing the client.