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?

Choice A reason:

Supplemental therapy refers to the use of additional substances or interventions to support and enhance the primary treatment. This is not relevant to the scenario described, where antibiotics are given while awaiting culture results. Supplemental therapy does not describe the preemptive use of antibiotics based on clinical judgment without confirmed microbiological evidence.

Choice B reason:

Replacement therapy typically involves providing the body with necessary substances that it is lacking, such as insulin for diabetes or thyroid hormones for hypothyroidism. This term does not apply to the scenario of administering antibiotics while waiting for culture results. Replacement therapy is used to restore normal function when the body is deficient in certain hormones or enzymes, not for treating infections.

Choice C reason:

Empiric therapy is the correct term for the administration of antibiotics based on clinical signs and symptoms before the exact cause of the infection is confirmed by culture results. This approach is used to promptly manage infections

and prevent their spread while waiting for detailed diagnostic information. It is a common practice in medicine to

Choice A reason:

Monitoring the Glasgow Coma Scale (GCS) is used to assess a client's level of consciousness, typically in cases of head injury or altered mental status. It is not relevant to the assessment of a pressure injury, which requires evaluating the risk factors and extent of skin damage.

Choice B reason:

Completing the Braden Scale is the appropriate action for assessing a client with a pressure injury. The Braden Scale evaluates risk factors for pressure ulcers, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This tool helps in creating an effective care plan to prevent further skin breakdown and manage existing ulcers.

Choice C reason:

Initiating a Brudzinski flow sheet pertains to neurological assessment, specifically testing for signs of meningitis. It is not relevant to the assessment or management of pressure injuries in a paraplegic client.

Choice D reason:

Assessing for Babinski's sign is a neurological test to evaluate corticospinal tract function. While important in a complete neurological examination, it does not address the specific needs related to pressure injury assessment and management.