A nurse is attending to a patient who suddenly experiences numbness and weakness on the right side of their body, including their arm and leg. The nurse also observes a distinct droop on the right side of the patient’s face. After reporting these findings to the healthcare provider, the nurse receives several prescriptions for the patient, including an immediate CT scan of the head. What should be the nurse’s first course of action?

Choice A rationale If a patient suddenly experiences numbness and weakness on the right side of their body, including their arm and leg, and a distinct droop on the right side of the patient’s face, these are warning signs of a stroke. The nurse’s first course of action should be to initiate two large- bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy. This is because rapid administration of fibrinolytic therapy can significantly improve outcomes in patients with acute ischemic stroke. Choice B rationale Continuous observation for transient episodes of neurologic dysfunction is important, but the immediate priority is to prepare for potential fibrinolytic therapy. Choice C rationale Elevating the head of the bed to 30 degrees and keeping the head and neck in neutral alignment can be beneficial in certain situations, but it is not the immediate priority in this scenario. Choice D rationale Administering aspirin can help prevent further clot formation and platelet aggregation in patients with acute coronary syndrome or those at high risk of cardiovascular disease. However, in the case of a suspected stroke, immediate medical evaluation and potential fibrinolytic therapy are the priorities.