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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.
Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.
Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.
Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.
Correct Answer is B
Explanation
Choice A reason: Eating high-protein foods to achieve ideal body weight is generally a healthy practice, but it is not directly related to the management of the client's current condition involving pain in the toe.
Choice B reason: Patients with gouty arthritis should avoid acetylsalicylic acid (aspirin) as it can lead to an increase in uric acid levels, potentially exacerbating gout attacks. Instead, medications that do not affect uric acid levels should be used for pain relief.
Choice C reason: Wrapping joints with an elastic bandage can provide support and reduce swelling, but it is not the primary intervention for sudden pain in the toe following an appendectomy, especially when the patient has a history of gouty arthritis.
Choice D reason: Supporting joints in an extended position while resting can provide comfort and may prevent stiffness, but it does not address the acute management of gouty arthritis or diabetic complications that could be causing toe pain.
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