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Patient Data

Exhibits

The nurse performs an initial rapid assessment of the client and observes facial drooping and garbled speech.

Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of

as evidenced by .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Rationale for Correct Choices:

  • Stroke: The combination of facial droop, garbled speech, and sudden onset of symptoms in an older adult is strongly indicative of a stroke. The extremely elevated blood pressure supports this diagnosis as hypertension is a major risk factor and often occurs during acute cerebrovascular events.
  • Garbled speech: Sudden difficulty in articulating words is a common symptom of both ischemic and hemorrhagic strokes. It reflects disruption of brain areas responsible for language, making this a key diagnostic indicator of a neurologic emergency.

Rationale for Incorrect Choices:

  • Malignant hypertension: While the blood pressure is dangerously high, malignant hypertension typically presents with signs of end-organ damage like chest pain, vision changes, or renal impairment. It is not primarily defined by focal neurological signs like facial droop or speech issues.
  • Intoxication: Although alcohol can cause slurred speech, it does not explain the presence of facial asymmetry. Stroke must be prioritized in differential diagnosis when focal deficits are present, regardless of alcohol intake.
  • Allergic reaction: Facial droop and garbled speech are not typical of an allergic reaction, which more commonly presents with symptoms such as urticaria, airway swelling, or hypotension.
  • Neurological deficits: This term is accurate but too broad. Specific symptoms such as “garbled speech” provide clearer clinical evidence of stroke and should be used over general terms.
  • Report of alcohol consumption: While relevant to the history, this is not a clinical finding that explains the observed neurological signs. It may distract from recognizing a true medical emergency like stroke.
  • Vital signs: Although the blood pressure is elevated, vital signs alone are not sufficient evidence for stroke. Neurological symptoms are more specific and diagnostic.


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Related Questions

Correct Answer is ["C","D","E"]

Explanation

Rationale:
A. The client should be monitored closely for persistent nausea or vomiting: While relevant, this is a nursing action and not critical SBAR content unless complications arise. It's not essential in a handoff unless persistent or severe.

B. A large number of family members are in the surgical waiting area: This is not directly relevant to the client’s clinical condition or care priorities, and does not belong in an SBAR handoff unless family poses an immediate concern.

C. A patient controlled analgesic (PCA) pump is prescribed and needs to be started as soon as possible: This is critical treatment information for continuity of pain management and should be communicated clearly during the SBAR handoff.

D. Surgical dressing is clean, dry, and intact and neurovascular status is within normal limits: Postoperative wound and neurovascular assessment findings are essential for monitoring surgical outcomes and early complications.

E. Client history includes heart failure and aphasia from a previous stroke: Medical history directly influences postoperative care decisions and risk for complications; it must be included in the background section of SBAR.

Correct Answer is A

Explanation

Rationale:
A. "Chest physiotherapy should be performed twice a day before a meal.” Chest physiotherapy helps clear mucus from the lungs and is most effective when done before meals to prevent vomiting and optimize lung function and oxygenation.

B. "Administer a cough suppressant every 8 hours." Cough suppressants are generally avoided in cystic fibrosis because coughing is necessary to mobilize and expel thick secretions from the airways.

C. "Energy should be conserved by scheduling minimally strenuous activities." Physical activity is encouraged to enhance lung expansion and mucus clearance. Energy conservation is not the priority unless the child is acutely ill.

D. "Maintain supplemental oxygen at 4 to 6 L/minute." High-flow oxygen is not routinely used and may suppress respiratory drive. Oxygen is used with caution and only as prescribed in advanced disease or during exacerbations.

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