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 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. Which intervention should the nurse perform in the immediate management of the client?
Administer aspirin to prevent further clot formation and platelet clumping.
Maintain elevated positioning of the dependent joints on the affected side.
Verify prescribed laboratory tests include prothrombin time and platelet count.
Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
The Correct Answer is D
A. Administering aspirin is not appropriate at this time, as it may delay treatment for a stroke if that is the underlying cause.
B. Maintaining elevated positioning of the dependent joints is not a priority in this acute situation and does not address the immediate needs of the client showing signs of possible stroke.
C. Verifying laboratory tests like prothrombin time and platelet count is important but is not an immediate intervention that addresses the acute condition.
D. Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is crucial because the client presents with signs of a potential stroke. Rapid identification and treatment are essential to improving outcomes in acute ischemic stroke cases.
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Correct Answer is D
Explanation
A. Administering aspirin is not appropriate at this time, as it may delay treatment for a stroke if that is the underlying cause.
B. Maintaining elevated positioning of the dependent joints is not a priority in this acute situation and does not address the immediate needs of the client showing signs of possible stroke.
C. Verifying laboratory tests like prothrombin time and platelet count is important but is not an immediate intervention that addresses the acute condition.
D. Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is crucial because the client presents with signs of a potential stroke. Rapid identification and treatment are essential to improving outcomes in acute ischemic stroke cases.
Correct Answer is C
Explanation
A. While frequent mouth care is important, it is not the most immediate concern during an active seizure. The priority is to maintain airway patency and prevent aspiration.
B. Maintaining a semi-Fowler's position may be beneficial, but the client’s level of consciousness and the presence of seizures require more immediate interventions focused on airway management.
C. Ensuring oral suction is available is essential for the client who is unconscious and experiencing seizures, as it allows for rapid intervention to clear secretions and prevent aspiration, which is critical for airway protection.
D. Keeping the room at a comfortable temperature is important for the overall comfort of the client, but it does not directly address the acute management of seizures and airway concerns.