A nurse is caring for a patient who suddenly experiences right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the 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 The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain. Choice B rationale While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority. Choice C rationale Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority. Choice D rationale Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.