The nurse is caring for a patient who reports sudden right-sided numbness and weakness of the arm and leg.
The nurse also observes a distinct right-sided facial droop.
After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the patient, including a STAT computerized tomography scan of the head.
What intervention should the nurse perform in the immediate management of the patient?
Initiate bilateral intermittent sequential pneumatic compression devices.
Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
Maintain elevated positioning of the dependent joints on affected side.
Obtain a focused history to determine recent bleeding and use of anticoagulants.
The Correct Answer is B
Choice A rationale
Initiating bilateral intermittent sequential pneumatic compression devices is not the most appropriate immediate intervention for a patient showing signs of a possible stroke. These devices are typically used to prevent deep vein thrombosis in patients who are immobile, not for stroke management.
Choice B rationale
Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is the correct intervention. This position can help reduce intracranial pressure and facilitate venous drainage. In the case of a suspected stroke, it’s crucial to maintain proper cerebral blood flow.
Choice C rationale
Maintaining elevated positioning of the dependent joints on the affected side is not the immediate priority in stroke management. While it’s important to prevent contractures and maintain functional positioning, the immediate concern is to stabilize the patient’s condition.
Choice D rationale
Obtaining a focused history to determine recent bleeding and use of anticoagulants is important, but it’s not the first intervention. While this information will be necessary for the healthcare provider to determine the appropriate course of treatment, the immediate priority is to manage the patient’s acute symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Observing for signs of depression is the most important intervention for the nurse to include in the client’s plan of care. This patient has a history of struggling with weight management, diabetes mellitus, and hypertension, and is now approved for gastroplasty. Weight management surgery can have significant psychological implications, and patients may experience depression or other emotional issues. Identifying signs of depression and providing appropriate support and resources is crucial for the client’s overall well-being and successful outcomes.
Correct Answer is D
Explanation
The correct answer is D. The practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients is best assigned to an adult who is one day postoperative for a laparoscopic cholecystectomy. This client’s care involves routine postoperative care and monitoring, which is within the PN’s scope of practice. The other clients have more complex needs that require the higher level of education and skills of an RN.
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