A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action?

Question

Quizplus · Accepted Answer

A flaccid extremity and change in verbal ability are symptoms of a stroke, which is considered an emergency. Clients with stroke symptoms are immediately triaged using a special team and set of tools to determine the correct course of action with the goal of preventing further brain damage. In any emergency, the first priority nursing action is to maintain a patent airway (Option C). Depending on the mechanism of injury, the symptoms may include changes in airway clearance, which is a priority. The nurse, or another member of the emergency department or stroke alert team, will prepare the client for an immediate head CT scan to rule out a hemorrhagic stroke and determine the location and extent of the injury (Option D). This person will also ensure that the client has 2 large-bore IV lines for rapid infusion of fluids or medications as needed (Option B). (Option A) It is vital to determine the onset of symptoms as thrombolytic medications are used in a short time frame (typically within 4.5 hours of onset). Thrombolytic medications are used only in ischemic strokes, so the head CT must be completed to confirm the type of stroke (ischemic versus hemorrhagic). With all of these interventions, the priority nursing actions remain the same: ABC - airway, breathing, and circulation. Educational objective: In any emergency, the primary nursing interventions are the ABCs. A patent airway should be maintained while other care is provided and throughout the emergency treatment process.

A Client Is Brought to the Emergency Department by Emergency