Hesi RN Exit Proctored Exam
The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which intervention should the nurse should perform in the immediate management of the client?
Explanation & Rationale
A. Obtaining a focused history is important for understanding the client’s condition but is not the immediate priority in acute stroke management. B. Raising the head of the bed to 30 degrees while keeping the head and neck in neutral alignment is essential in stroke management to promote cerebral perfusion and prevent increased intracranial pressure. C. Maintaining elevated positioning of dependent joints is not as critical as ensuring proper alignment of the head and neck in the context of stroke care. D. Initiating bilateral intermittent sequential pneumatic compression devices is relevant for preventing deep vein thrombosis but is not the priority in managing acute stroke symptoms.
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