CVA (Stroke) questions with correct answers

A 78-year-old client is admitted to the emergency department with numbness and weak- ness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of head. 4. Notify the speech pathologist for an emergency consult. - Answer 1) The drug rt-PA may be administered, but a cerebrovascular accident (CVA) must be veri- fied by diagnostic tests prior to administering it. rt-PA helps dissolve a blood clot, and it may be administered if an ischemic CVA is verified, rt-PA would not be given if the client were experiencing a hemorrhagic stroke. 2) Teaching is important to help prevent another CVA, but it is not the priority intervention on admission to the emergency department. Slurred speech indicates problems that may interfere with teaching. 3)* A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment. 4) The client may be referred for speech deficits and/or swallowing difficulty, but referrals are not priority in the emergency department. TEST-TAKING HINT: When "priority" is used in the stem, all answer options may be appropriate for the client situation, but only one answer is priority. The client must have a documented diagnosis before treatment is started. The nurse is assessing a client experiencing motor loss as a result