The nurse is caring for a client who arrives at the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. After obtaining vital signs, the nurse should implement which intervention?
Initiate bilateral intermittent sequential pneumatic compression devices.
Place an indwelling urinary catheter and measure strict intake and output.
Notify the stroke team to assist with acute assessment and management.
Administer aspirin to prevent further clot formation and platelet clumping.
The Correct Answer is C
Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.
Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.
Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.
Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Fat emboli are typically associated with long bone fractures and not commonly linked with dehydration or immobility.
Choice B reason: Deep vein thrombosis (DVT) is a common condition in immobile patients, and redness and swelling in the calf are classic signs.
Choice C reason: While infection can cause redness and swelling, it is usually accompanied by other signs such as fever, which is not mentioned here.
Choice D reason: Pulmonary embolism is a complication that can arise from DVT but would not be the direct cause of calf redness and swelling.
Correct Answer is B
Explanation
Choice A reason: Telling the charge nurse and refusing to administer the placebo could be seen as insubordination and does not address the ethical concerns associated with placebo use.
Choice B reason: Discussing ethical concerns with the healthcare provider is the most appropriate action as it addresses the potential breach of patient trust and informed consent associated with placebo use.
Choice C reason: Administering the placebo as prescribed without addressing the ethical implications could compromise the nurse's professional integrity and the patient's trust.
Choice D reason: Informing the client that a placebo was prescribed could undermine the treatment plan and the provider-patient relationship, potentially causing harm to the client.

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