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    HESI PN Exit 2023 Proctored Exam
    Select All That Apply

    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. 1915: Client arrives via personal car to emergency department with facial drooping and garbled speech. Click to highlight the data that indicate the client is in need of immediate health interventions.

    Explanation & Rationale

    Choice A rationale: The client’s presentation of a noticeable facial droop and garbled speech are classic symptoms of a stroke. These symptoms indicate that the brain is not receiving enough oxygen, which can lead to permanent damage if not treated immediately. Therefore, this client requires immediate health interventions. Choice B rationale: This choice is identical to Choice A. The client’s noticeable facial droop and garbled speech are indicative of a stroke and require immediate attention. Choice C rationale: This choice is also identical to Choices A and B. The client’s symptoms are indicative of a stroke, which is a medical emergency that requires immediate intervention. Choice D rationale: While the change in the client’s speech after having a few drinks at a restaurant could be due to alcohol consumption, it could also be a symptom of a stroke, especially when combined with the facial droop. However, this choice does not directly indicate the need for immediate health interventions as it lacks the specificity of the symptoms compared to Choices A, B, and C. Choice E rationale: The time of arrival and mode of transportation do not directly indicate the need for immediate health interventions. However, the mention of facial drooping and garbled speech upon arrival at the emergency department reinforces the urgency of the situation, as these are classic symptoms of a stroke. In conclusion, Choices A, B, C, and E all highlight data that indicate the client is in need of immediate health interventions due to potential stroke symptoms. It’s important to note that strokes require immediate medical attention to minimize brain damage and potential complications. Normal ranges for lab parameters would not apply in this scenario as it’s based on clinical observations rather than laboratory findings.

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