The nurse is caring for a client who reports a sudden, severe headache, and facial numbness.The nurse asks the client to smile and observes an uneven smile with a facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?
Place an indwelling urinary catheter and measure strict intake and output.
Maintain elevated positioning of the dependent joints on affected side.
Raise the head of the bed to 30 degrees keep head and neck in neutral alignment.
Determine when symptoms began and if improved or worsened since onset.
The Correct Answer is D
A) Incorrect- While monitoring urinary output is important for overall assessment, it is not the most critical intervention in this situation of suspected stroke. The client's neurological symptoms take precedence.
B) Incorrect- Positioning might be relevant to preventing complications, but it is not the highest priority intervention in this situation. The focus should be on assessing the client's neurological status and determining appropriate intervention.
C) Incorrect- Although head positioning is relevant for intracranial pressure management, it is not the immediate priority. The nurse should first assess the time of symptom onset and determine if the client is experiencing an acute stroke.
D) Correct- The client's symptoms, including sudden severe headache, facial numbness, facial droop, and weakness on one side, are suggestive of a stroke. The nurse should prioritize assessing the time of symptom onset, as time is a crucial factor in determining the appropriate intervention. Rapid intervention can improve outcomes in stroke cases, especially when considering interventions like thrombolytic therapy. The other options are not as directly relevant to the immediate management of a suspected stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
The level of hypoxemia that the child may have experienced during the submersion depends on several factors, but the most important ones are:
- The **temperature of water**: Cold water can induce a diving reflex, which lowers the heart rate and oxygen consumption, and may protect the brain from hypoxic injury¹². Cold water can also cause laryngospasm, which prevents water aspiration but also impairs gas exchange.
- The **amount of time the child was submerged**: The longer the submersion, the more severe the hypoxemia and the higher the risk of brain damage and death. The survival rate decreases significantly after 5 minutes of submersion³.
The other factors are less relevant or not directly related to the level of hypoxemia:
- The **weight of the child**: This may affect the buoyancy and the ability to float or swim, but not the oxygen consumption or gas exchange during submersion¹.
- The **oxygen concentration of the ambient air**: This may affect the pre-submersion oxygen saturation, but not the rate of oxygen depletion or gas exchange during submersion¹.
- The **witnessing of the fall into the pool**: This may affect the time to rescue and resuscitation, but not the level of hypoxemia during submersion.
Correct Answer is A
Explanation
This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the flowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.
The other options are not correct because:
B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.
C. The supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not affect the oxygen delivery or uptake.
D. The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen flow or diffusion.
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