Difficulty: Medium
Average Score: 79%
Simulated
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
Correct answer
C
Rationale
For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.