Difficulty: Medium
Average Score: 65%
Simulated
A 76-year-old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time?
Correct answer
C
Rationale
Assessing the client's symptoms is crucial to monitor for stroke progression and guide interventions, especially with changing vital signs.