The nurse reports that a client is at risk for a stroke based on which assessment finding?

Choice A reason: Determining the quickest onset is important but secondary to matching pain severity with dosing. Pain scale rating guides appropriate medication selection, as prescriptions are dosed for specific pain levels, ensuring effective relief without overuse, making this action less critical initially.

Choice B reason: Asking the client to choose medication is inappropriate, as patients lack expertise to select based on pharmacology. Pain scale rating informs the nurse’s decision, aligning with prescribed doses, ensuring safe and effective analgesia, making this action incorrect for professional nursing practice.

Choice C reason: Documenting pain is necessary but not the first action. Comparing pain scale rating with dosing ensures appropriate medication selection, addressing pain effectively before recording. Documentation follows intervention, making this action secondary to selecting the correct analgesic based on severity.

Choice D reason: Comparing pain scale rating with prescribed dosing is critical, as PRN analgesics are dosed for specific pain levels (e.g., mild vs. severe). This ensures the nurse selects the appropriate medication, optimizing pain relief while minimizing overdose risk, making it the priority action before administration.

Choice A reason: Tracheostomy placement is for prolonged airway management, not immediate in traumatic brain injury (TBI). NGT insertion addresses acute needs like gastric decompression or feeding, as TBI may impair swallowing, making this procedure less urgent than managing intracranial complications.

Choice B reason: Central line insertion provides vascular access but is not specific to TBI. NGT insertion prevents aspiration or manages gastric contents, critical in TBI with altered consciousness, making central lines secondary, as they address fluid or medication needs, not TBI-specific issues.

Choice C reason: NGT insertion is anticipated, as traumatic brain injury often impairs swallowing or consciousness, increasing aspiration risk. The tube decompresses the stomach or delivers nutrition, preventing complications like pneumonia, making it a priority procedure to support TBI management and patient stability.

Choice D reason: Pacemaker placement addresses cardiac arrhythmias, unrelated to traumatic brain injury. NGT insertion manages gastric or nutritional needs in TBI, where neurological deficits are primary, making pacemakers irrelevant, as TBI does not typically involve acute cardiac conduction issues.