A hospitalized patient has become unresponsive. The left side of the body is flaccid. The attending physician believes the patient may have had a hemorrhagic stroke. What is the nurse's priority intervention?
1. Move the patient to the critical care unit.
2. Assess blood pressure.
3. Assess the airway and breathing.
4. Observe urinary output.
3
Rationale 1: Moving the patient to the critical care unit is not a priority intervention.
Rationale 2: Blood pressure assessment is an important intervention but not the most vital.
Rationale 3: In any unconscious patient, the airway must be protected. Assessment of the current airway and breathing status is of highest priority and will continue to be.
Rationale 4: Urinary output assessment is an important intervention but not the most vital.
You might also like to view...
A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician
Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient? a. He will go into adrenal crisis. b. He will go into thyroid storm. c. His autoimmune disease will go into remission. d. Nothing; it is appropriate to stop the medication for 3 days.
The nurse is concerned that an older client exhibits lethargy and headache. What other assessments does the nurse perform immediately? Select all that apply.
1. Mental status 2. Orthostatic blood pressure 3. Daily weight 4. Long tongue furrows 5. Forearm tenting of the skin
What is stroke volume?
a. the volume of blood pumped by the heart in 1 minute b. the measurement of the ratio of stroke volume to compliance of the arterial system c. the bounding of blood flow in an artery d. the measurement of blood that enters the aorta with each ventricular contraction
A community health nurse cares for homeless clients weekly at a local shelter. The nurse recognizes that which are ongoing problems for many homeless individuals? Select all that apply
A) Alcoholism and thermoregulation B) Sexually transmitted diseases (STDs), including HIV disease C) Conditions related to dietary deficiencies D) Excess vitamin D from sun overexposure