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    HESI PN Exit 2023 Proctored Exam

    A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand. The triage nurse does a rapid assessment of the client. Exhibits Select one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of dropdown as evidenced by dropdown.

    Explanation & Rationale

    Choice B rationale: Stroke is a condition that occurs when the blood supply to a part of the brain is interrupted, causing brain tissue damage. Facial drooping and garbled speech are common signs of stroke, especially if they occur suddenly and on one side of the face. Stroke is a medical emergency that requires immediate treatment to prevent further brain damage and complications Choice C rationale: An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation. Choice D rationale: Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.

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