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 D

Explanation

Choice A reason:

Steatorrhea is the presence of excess fat in the stool, which indicates malabsorption issues. However, it is not what a guaiac stool test is designed to detect. Specialized fat stains and tests are used to identify steatorrhea.

Choice B reason:

Bacteria presence in stool is usually evaluated through stool culture tests, not the guaiac stool test. A stool culture helps identify bacterial infections in the gastrointestinal tract.

Choice C reason:

Parasites in stool are detected using ova and parasite (O&P) exams, not the guaiac stool test. The O&P exam identifies microscopic parasites and their eggs.

Choice D reason:

The guaiac stool test is used to detect the presence of occult (hidden) blood in the stool. It helps identify gastrointestinal bleeding that is not visible to the naked eye, which can be a sign of conditions such as ulcers, polyps, or colorectal cancer.

A. "I will wear earphones during this test." B. "A small probe is placed inside my ear." C. "Small electrodes are placed on my scalp." D. "A tuning fork is placed on my head."

Correct Answer is D

Explanation

Choice A reason: The Rinne test does not involve wearing earphones. This statement may indicate a misunderstanding or confusion with other hearing tests that use earphones to deliver sounds. The Rinne test specifically uses a tuning fork.

Choice B reason: The Rinne test does not involve inserting any probes into the ear. This statement is incorrect and indicates the client does not fully understand the procedure, which involves comparing air and bone conduction of sound.

Choice C reason: Small electrodes placed on the scalp are used in other diagnostic tests, such as EEGs (electroencephalograms), to measure electrical activity in the brain. This is not relevant to the Rinne test, which assesses hearing using a tuning fork.

Choice D reason: This is the correct answer. In the Rinne test, a tuning fork is struck and then placed on the mastoid process (behind the ear) and near the ear canal to compare bone and air conduction of sound. This statement indicates the client understands the test procedure.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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