An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm.

After confirming the presence of the spasms, which action should the nurse take?

Choice A rationale:

Beginning continuous observation for transient episodes of neurologic dysfunction is important in the assessment and monitoring of the client's condition. However, in this scenario, the client is presenting with symptoms suggestive of a possible stroke or cerebrovascular event, and time is crucial. The nurse should prioritize actions that can lead to prompt diagnosis and treatment.

Choice B rationale:

Starting two large bore intravenous (IV) catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the most urgent action. The client's symptoms, including sudden right-sided numbness, weakness, and facial droop, are indicative of a possible ischemic stroke. IV fibrinolytic therapy is time-sensitive and has a limited window of effectiveness. Establishing IV access and determining eligibility for this therapy should be the nurse's top priority to potentially improve the client's outcome.

Choice C rationale:

Administering aspirin to prevent further clot formation and platelet clumping is an important intervention in the treatment of ischemic stroke. However, it should not be the first action in this scenario. The priority is to assess for eligibility for IV fibrinolytic therapy, as this intervention has a more immediate impact on reversing the stroke's effects.

Choice D rationale:

Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is a reasonable nursing intervention to prevent complications such as aspiration and promote optimal cerebral blood flow. However, it is not the most urgent action in this case. The priority should be on assessing and potentially treating the stroke with IV fibrinolytic therapy.

Choice A rationale:

Correcting electrolytes that are out of normal range is a crucial goal of therapy for this client. In diabetic ketoacidosis (DKA), the body’s cells are unable to use glucose for energy due to a lack of insulin. This leads to the breakdown of fat for energy, producing ketones as a by-product. Ketones are acidic and can cause the blood’s pH to decrease, leading to metabolic acidosis. This process also leads to an increased production and excretion of electrolytes such as potassium and sodium. Therefore, correcting these electrolyte imbalances is a key goal of therapy.

Choice B rationale:

While promoting oxygenation to tissues is generally important in critical care, it is not a specific goal in the management of DKA. The primary issues in DKA are metabolic in nature, including hyperglycemia, ketosis, and acidosis.

Choice C rationale:

Preventing hyperventilation is not a specific goal in the management of DKA. Hyperventilation in DKA is a compensatory mechanism for metabolic acidosis (Kussmaul breathing). The body tries to expel more carbon dioxide to reduce the acidity of the blood.

Choice D rationale:

Reversing dehydration is another important goal of therapy for this client. In DKA, high blood glucose levels lead to osmotic diuresis, where water is drawn into the urine from the blood, leading to dehydration. This can cause hypotension and reduced tissue perfusion. Therefore, reversing dehydration through fluid replacement is a key part of treatment.

Choice E rationale:

Replacing insulin is a fundamental goal of therapy for this client. Insulin deficiency is the primary cause of DKA. Insulin allows glucose to enter cells where it can be used for energy, preventing the breakdown of fat for energy and the subsequent production of ketones.

Choice F rationale:

Providing respiratory support may be necessary in severe cases of DKA where the patient’s compensatory respiratory efforts are insufficient to maintain adequate gas exchange. However, it is not one of the primary goals of therapy in DKA management.