An older client is brought to the ED with numbness and weakness of the left arm and slurred speech starting 30 minutes prior to arrival. Which nursing intervention is a priority?

Prepare to take the client for a STAT CT of the head.

Prepare to administer recombinant tissue plasminogen activator (rtPA).

Notify speech pathologist for an emergency consult.

Discuss the precipitating factors that caused the symptoms.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Preparing to take the client for a STAT CT of the head is crucial to quickly diagnose a possible stroke. Rapid imaging is essential to determine the type of stroke (ischemic or hemorrhagic), guiding appropriate treatment and improving outcomes. This immediate action is key in stroke management.

Choice B reason:

Administering rtPA is an appropriate intervention for an ischemic stroke but only after confirmation through imaging. Without imaging, there is a risk of worsening a potential hemorrhagic stroke. Hence, it is not the initial priority before confirming the diagnosis.

Choice C reason:

Notifying a speech pathologist for an emergency consult is relevant for assessing and managing speech and swallowing issues but is not the immediate priority. The primary focus should be on diagnosing and addressing the cause of the acute symptoms.

Choice D reason:

Discussing precipitating factors that caused the symptoms can be part of the assessment but is not the priority in the acute phase. Immediate imaging and medical intervention take precedence to mitigate the effects of a potential stroke.

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Correct Answer is A

Explanation

Choice A reason: This is the correct answer. Dantrolene is the medication of choice for treating malignant hyperthermia, which is indicated by muscle rigidity and a rapid rise in body temperature. It works by reducing calcium release in muscles, thereby alleviating the symptoms.

Choice B reason: Neostigmine is an acetylcholinesterase inhibitor used to treat myasthenia gravis and to reverse the effects of certain muscle relaxants post-surgery. It is not indicated for the treatment of malignant hyperthermia.

Choice C reason: Vecuronium is a muscle relaxant used during anesthesia to induce muscle relaxation. It is not a treatment for malignant hyperthermia and does not address the symptoms of muscle rigidity and hyperthermia.

Choice D reason: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. It has no role in the treatment of malignant hyperthermia and is therefore not relevant to this scenario.

A. Restrain the client. B. Move objects away from the client. C. Place the client on his back. D. Insert a padded tongue blade into the client’s mouth.

Correct Answer is B

Explanation

Choice A reason:

Restraint during a seizure can lead to injury. It is important to allow the seizure to run its course while ensuring the client is safe from harm. The priority is to protect the client from injury without restraining them, as this can cause fractures or muscle damage.

Choice B reason:

Moving objects away from the client helps prevent injury during a seizure. Clearing the area ensures that the client does not hit anything during the convulsions, reducing the risk of injury. This is a safe and effective measure to protect the client.

Choice C reason:

Placing the client on their back is not recommended during a seizure as it can increase the risk of aspiration if the client vomits. Instead, the client should be turned onto their side (recovery position) to keep the airway clear and prevent choking.

Choice D reason:

Inserting a padded tongue blade into the client’s mouth is outdated and dangerous. It can cause dental damage or block the airway. There is also a risk of injury to both the client and the person attempting to insert the object. It is no longer recommended.

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An older client is brought to the ED with numbness and weakness of the left arm and slurred speech starting 30 minutes prior to arrival. Which nursing intervention is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the operating room is caring for a client who suddenly develops muscle rigidity and a rise in body temperature. What emergency medication should the nurse expect to receive an order to start administering?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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