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 C

Explanation

Choice A reason:

Responding with "This hospital might use a different manufacturer, so you must take the medication" dismisses the client’s concern and does not verify if there has been an error in medication dispensing. It’s important for nurses to validate patient concerns rather than making assumptions about the situation.

Choice B reason:

Stating "This is the medication prescribed by your provider" assumes correctness without verifying the client's concern. Although this reassures the patient of prescription accuracy, it fails to address the immediate discrepancy noted by the client, potentially overlooking a mistake.

Choice C reason:

Asking "What does your usual pill look like?" involves the client in the medication verification process, validating their observation and ensuring that the medication is correct. This response demonstrates respect for the client's knowledge and enhances safety by cross-checking details before administration.

Choice D reason:

Assuming "This pill is probably from a different lot number than yours at home" could be misleading and fails to confirm the medication’s accuracy. It’s important to thoroughly investigate the client’s concern rather than making presumptions about manufacturing details.

A. WBC count 8,000/mm³ B. hemoglobin 16 g/dL C. serum albumin 3.2 g/dL D. INR 0.9

Correct Answer is C

Explanation

Choice A reason: A WBC count of 8,000/mm³ falls within the normal range (4,000-11,000/mm³) and does not indicate a specific risk for delayed wound healing. It helps assess the immune response but is not a direct marker for nutrition or tissue repair.

Choice B reason: A hemoglobin level of 16 g/dL is within the normal range (13.8-17.2 g/dL for men, 12.1-15.1 g/dL for women) and indicates adequate oxygen-carrying capacity. While essential for overall health, it does not directly correlate with the risk of delayed wound healing in this context.

Choice C reason: This is the correct answer. Serum albumin levels are a marker of nutritional status. A level of 3.2 g/dL is on the lower side of the normal range (3.5-5.0 g/dL) and indicates potential malnutrition, which can impair wound healing by limiting the availability of necessary proteins and nutrients for tissue repair.

Choice D reason: An INR (International Normalized Ratio) of 0.9 is within the normal range (0.8-1.2) and reflects normal blood clotting. While important for understanding coagulation status, it does not indicate a direct risk for delayed wound healing related to nutrition or protein levels.

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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

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