​​​​​​Patient Data

Exhibits

Review H and P, nurse's notes, and laboratory results.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

Rationale

A. This response acknowledges the client's need for reassurance and informs them of the nurse's plan. However, it may not address the immediate need for comfort and connection expressed by the client.

B. This response may come across as dismissive or insensitive to the client's emotional and psychological needs. It could potentially increase anxiety or distress in an already vulnerable client.

C. Sitting beside the client demonstrates empathy and provides physical presence, which can be reassuring and comforting. However, it is not practical as the nurse has other duties to attend to.

D. It addresses the patient's immediate emotional needs without compromising the nurse's ability to perform their duties.

Rationale

A. This action helps maintain adequate cerebral perfusion pressure and venous drainage, which is important in suspected stroke cases. It supports optimal cerebral blood flow and reduces the risk of increased intracranial pressure. However, it's not the immediate intervention required for this client. The primary focus initially is on diagnostic evaluation and stabilization.

B. Elevating the joints on the affected side can help reduce dependent edema and promote circulation. This intervention is part of ongoing nursing care to prevent complications like deep vein thrombosis (DVT) in stroke patients who may have reduced mobility. While important, it is not the immediate priority in the acute phase of management.

C. Gathering a focused history is crucial to understanding potential causes or exacerbating factors contributing to the client's symptoms While important, it is not the immediate priority in the acute phase of management.

D. Intermittent pneumatic compression devices (IPC) are used to prevent deep vein thrombosis (DVT) by enhancing venous return and preventing stasis in the lower extremities. While DVT prevention is important in stroke patients, it is not the immediate intervention required for the client's acute neurological symptoms.