Difficulty: Medium
Average Score: 80%
Simulated
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct answer
A: Stroke, B: Maintain patent airway, Initiate tissue plasminogen activator (tPA) , C: Vital signs and neurological status, Affected side deficits
Rationale
The client's condition is most consistent with a Stroke, a medical emergency caused by interrupted blood flow to the brain. The most critical actions are to maintain a patent airway due to potential decreased gag reflex and risk of aspiration, and to initiate tissue plasminogen activator (tPA) if the client is an eligible candidate, as this clot-busting drug is time-sensitive and crucial for improving outcomes in ischemic strokes. The key parameters to monitor are vital signs and neurological status to detect any deterioration or improvement, and affected side deficits (e.g., weakness, numbness) to gauge the extent of the stroke and response to treatment. Starting a peripheral IV is a supportive action, and administering seizure medication is not a primary intervention for a new stroke. Monitoring for increased ICP is more specific to a closed head injury, and lung sounds, while important, are not a primary parameter for stroke progression.