1900: The client arrives with left facial droop, inability to move her left arm and leg, and expressive aphasia. According to the husband, they were out eating dinner, and the symptoms started suddenly, and she fell to the ground. The symptoms started 45 minutes prior to arrival at the ED. Past medical history includes atrial fibrillation, hypertension, diabetes mellitus, and hyperlipidemia.
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress
Action to Take: Transport the client for computed tomography (CT) scan | Obtain a manual blood pressure | Prepare the client for a lumbar puncture (LP) | Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood Glucose) | Prepare the client for Magnetic Resonance Imaging (MRI)
Potential Conditions: Bell’s Palsy | Complex Partial Seizure | Complex Migraine | Severe Hypoglycemia | Cerebral Vascular Accident
Parameters to Monitor: Glasgow Coma Scale (GCS) | Gait | Vital Signs | Orthostatic Blood Pressure | Visual Acuity
Action to Take: Transport the client for computed tomography (CT) scan | Obtain a manual blood pressure | Prepare the client for a lumbar puncture (LP) | Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood Glucose) | Prepare the client for Magnetic Resonance Imaging (MRI)
Parameters to Monitor: Glasgow Coma Scale (GCS) | Gait | Vital Signs | Orthostatic Blood Pressure | Visual Acuity
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