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Exhibits

The triage nurse does a rapid assessment of the client.

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A 70-year-old female presents to the emergency department (ED) through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

A.

noticeable facial droop

B.

garbled speech

C.

few drinks at a local seafood restaurant

D.

speech became difficult to understand.

Answer and Explanation

The Correct Answer is ["A","B","D"]

Rationale for correct Choices:

  • Noticeable facial droop: Facial drooping is a hallmark sign of a stroke. Early recognition is critical because prompt intervention, such as thrombolytic therapy, must occur within a narrow time window to prevent long-term neurological damage.
  • Garbled speech: Slurred or incomprehensible speech (dysarthria or aphasia) is another acute stroke symptom. It indicates potential involvement of the brain's language centers and requires immediate neuroimaging and evaluation.
  • Speech became difficult to understand: A sudden change in speech pattern strongly suggests an evolving neurologic event such as a transient ischemic attack (TIA) or stroke. Timely identification of symptom onset is essential for determining eligibility for time-sensitive stroke treatments like alteplase.

Rationale for Incorrect Choices:

  • Few drinks at a local seafood restaurant: While alcohol can cause slurred speech and sea food can result in allergic reaction, the patient reports with symptoms suggestive of a stroke, therefore this is not part of the immediate concerns.


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Related Questions

Correct Answer is C

Explanation

Rationale:
A. Apply bilateral eye patches while sleeping: Routine patching is not typically required after photocoagulation. This intervention may impair safety and independence unnecessarily, especially if only one eye was treated.

B. Arrange food on the plate in clockwise order: This technique supports clients with total blindness, but photocoagulation for macular degeneration usually preserves peripheral vision. Clock-face plate arrangement may not be necessary for partial vision loss.

C. Verbally identify self when entering the room: Clients with macular degeneration often lose central vision but retain peripheral vision. Verbal identification helps orient and reassure the client, supporting emotional comfort and safety in the postoperative period.

D. Use a white board to communicate ideas: White boards require intact central vision for reading. Clients with macular degeneration may struggle to see text, so verbal communication is generally more effective and appropriate.

Correct Answer is C

Explanation

Rationale:

A. "Are you the type of person who shares your problems easily?": This question explores communication style but may feel invasive or irrelevant to someone in acute distress. It does not directly address the client’s current emotional needs or offer support.

B. "What do you think is your primary goal to achieve this time?": Goal setting is important during the planning phase of care, but clients in overwhelming anxiety may not be ready for structured thinking. This question may increase pressure and exacerbate anxiety.

C. "Would you like me to sit with you for a while?": This offers immediate emotional support and conveys presence, which helps build trust and reduce anxiety. It is a therapeutic approach that meets the client’s most urgent need for calm and reassurance.

D. "Have you experienced changes in your life recently?": Life changes may contribute to anxiety, but exploring them is appropriate after the client feels emotionally safe and stable. The initial priority is to establish a calming presence, not to probe background stressors.

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