The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action?
Determine the time of symptom onset
Assess for the presence of headache
Determine the patient's drug allergies
Assess the patient's orientation
The Correct Answer is A
A. Determine the time of symptom onset: Establishing the exact time symptoms began is critical for stroke management, particularly to determine eligibility for thrombolytic therapy. Rapid intervention depends on accurate timing to maximize benefits and minimize risks.
B. Assess for the presence of headache: While headache may provide additional clinical information, it does not take priority over determining symptom onset, which directly guides treatment decisions in acute stroke.
C. Determine the patient's drug allergies: Identifying allergies is important before administering medications, but initial priority focuses on interventions that directly affect neurological outcomes and eligibility for acute therapies.
D. Assess the patient's orientation: Orientation assessment helps gauge neurological status but is secondary to establishing the timeline for intervention. Immediate treatment decisions are guided by onset and type of neurological deficits.
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Related Questions
Correct Answer is C
Explanation
A. Post-renal: Post-renal acute kidney injury occurs due to obstruction of urine flow in the urinary tract, such as from kidney stones or prostatic hypertrophy. A massive GI bleed does not directly cause urinary tract obstruction.
B. Intra-renal: Intra-renal injury refers to direct damage to kidney tissue from toxins, medications, or ischemia. While ischemia can occur, the primary risk from a massive GI bleed is systemic hypoperfusion rather than direct renal tissue injury.
C. Pre-renal: Pre-renal acute kidney injury results from decreased renal perfusion due to hypovolemia, hypotension, or shock. A massive GI bleed can cause significant blood loss and hypovolemia, reducing kidney perfusion and placing the patient at risk for pre-renal AKI.
D. Intrinsic renal: Intrinsic renal injury involves structural damage within the kidney, such as glomerulonephritis or acute tubular necrosis. Initial risk from a GI bleed is hemodynamic, making pre-renal injury more likely than primary intrinsic renal damage.
Correct Answer is C
Explanation
A. Infuse 1 unit of platelet: Platelet transfusion is indicated for thrombocytopenia or active bleeding related to low platelet counts. Acute adrenal insufficiency does not involve platelet depletion or coagulation defects. This intervention does not address the underlying hormonal crisis.
B. Restrict daily fluid intake: Clients with acute adrenal insufficiency are at risk for hypovolemia and hypotension due to aldosterone deficiency. Fluid restriction would worsen dehydration and circulatory collapse. Fluid replacement is typically required rather than restriction.
C. Admin hydrocortisone sodium: Acute adrenal insufficiency requires immediate glucocorticoid replacement to restore cortisol levels. Hydrocortisone sodium provides both glucocorticoid and some mineralocorticoid effects, helping stabilize blood pressure and metabolism. Prompt administration is critical to prevent adrenal crisis complications.
D. Give oral spironolactone: Spironolactone is a potassium-sparing diuretic and aldosterone antagonist. In adrenal insufficiency, aldosterone levels are already low, making this medication inappropriate. Its use could worsen hyperkalemia and hypotension.
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