Neurological Disorders Q 33

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A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

  

     A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

     B. Discuss the precipitating factors that caused the symptoms.

     C. Schedule for A STAT computer tomography (CT) scan of the head.

     D. Notify the speech pathologist for an emergency consultation.

    

    

Correct Answer: C. Schedule for A STAT computer tomography (CT) scan of the head.

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A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use rt-PA. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions. Demonstrates structural abnormalities, edema, hematomas, ischemia, and infarctions.

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Option A: This would make A not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. CT scan may not immediately reveal all changes, e.g., ischemic infarcts are not evident on CT for 8–12 hr; however, intracerebral hemorrhage is immediately apparent; therefore, emergency CT is always done before administering tissue plasminogen activator (t-PA). In addition, patients with TIA commonly have a normal CT scan.

Option B: Discussing the precipitating factors for teaching would not be a priority and slurred speech would indicate interference for teaching. Give family information about the expected outcome of the stroke, and counsel them to avoid doing things for the patient that he or she can do.

Option D: Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol. Maintain patient’s attention when talking with the patient, speak slowly, and give one instruction at a time; allow the patient time to process. Talk to aphasic patients when providing care activities to provide social contact.

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