Hesi RN Exit Proctored Exam
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. After obtaining vital signs, the nurse should implement which intervention?
Explanation & Rationale
A. Obtaining a focused history to determine recent bleeding and use of anticoagulants is crucial to evaluate the risk of hemorrhage and guide treatment decisions, especially considering the symptoms suggest a possible stroke. B. Initiating sequential pneumatic compression devices is not relevant to the immediate neurological symptoms. C. Administering aspirin is contraindicated without confirming whether the stroke is ischemic or hemorrhagic. D. Placing an indwelling urinary catheter is not an immediate priority compared to assessing the stroke symptoms.
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