A 63-year-old patient who began experiencing right arm and leg ...

[karlynnae]

A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?
 
  (Put a comma and a space between each answer choice A, B, C, D.)
  a. Obtain computed tomography (CT) scan without contrast.
  b. Infuse tissue plasminogen activator (tPA).
  c. Administer oxygen to keep O2 saturation >95.
  d. Use National Institute of Health Stroke Scale to assess patient.

Question 2

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy,
 
  which nursing diagnosis is the highest priority for this patient?
 
  a. Impaired transfer ability
  b. Risk for caregiver role strain
  c. Ineffective health maintenance
  d. Risk for unstable blood glucose level

[AngeliqueG]

Answer to Question 1

ANS:
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

Answer to Question 2

ANS: B
The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported.