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    HESI RN Medical Surgical 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. Which intervention should the nurse perform in the immediate management of the client?

    Explanation & Rationale

    A. Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is essential in the immediate management of a client with sudden, severe headache and neurological deficits suggestive of stroke. Time- sensitive interventions, such as IV fibrinolytic therapy, may be indicated if the client meets criteria for treatment.B. Administering aspirin to prevent further clot formation and platelet clumping is contraindicated in the acute management of a suspected stroke until hemorrhagic stroke is ruled out.C. Verifying prescribed laboratory tests include prothrombin time and platelet count is important for assessing coagulation status, but it is not the immediate intervention needed in this situation.D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority intervention in the acute management of a suspected stroke.

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