OLLIPILE 5.- The nurse walks into a client’s room and discovers the client has a new facial droop

QUESTION

OLLIPILE 5.- The nurse walks into a client’s room and discovers the client has a new facial droop. Place the action
the nurse should perform in priority order. Nursing Actions 1-Obtain blood glucose level. 2-Complete a neurological
assessment. 3-Notify the code stroke team. 4-Transport client to computerized tomography (CT) department.

ANSWER

When a nurse walks into a client’s room and discovers a new facial droop, it is crucial to prioritize actions for rapid assessment and potential intervention. The following is the priority order for nursing actions in this scenario:

1. Notify the code stroke team: The immediate priority is to activate the code stroke team. A new facial droop could be indicative of a stroke, and time is of the essence in stroke management. The code stroke team will initiate a rapid response protocol to evaluate the client promptly and determine the appropriate course of action.

2. Transport the client to the computerized tomography (CT) department:After notifying the code stroke team, the next priority is to facilitate the client’s rapid transfer to the CT department. A CT scan is essential for confirming or ruling out a stroke and identifying its type (ischemic or hemorrhagic). Time-sensitive decisions regarding treatment options depend on this diagnostic information.

3. Complete a neurological assessment: While waiting for the code stroke team and during transportation to the CT department, the nurse should perform a brief neurological assessment. This assessment includes evaluating other signs of stroke, such as changes in speech, motor strength, and sensory perception. Gathering additional clinical data will support the diagnostic process.

4. Obtain blood glucose level: Although checking the blood glucose level is an important aspect of stroke assessment, it is the lowest priority in this situation. The nurse should prioritize activating the code stroke team, ensuring rapid transport to the CT department, and conducting a neurological assessment to promptly address the potential stroke. Once these immediate actions are initiated, checking the blood glucose level can be done in parallel to rule out hypoglycemia, which may mimic stroke symptoms.

In summary, the priority order of nursing actions when encountering a client with a new facial droop is to first activate the code stroke team, followed by facilitating transportation to the CT department, conducting a neurological assessment, and then obtaining a blood glucose level. This sequence ensures timely evaluation and intervention in cases of suspected stroke.