The Emergency Department (ED) nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened.
Which additional clinical manifestation(s) should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? (Select all that apply.)
A) A carotid bruit.
The carotid artery (artery to the brain) is narrowed in clients with a brain attack (stroke). A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow.
B) Elevated blood pressure.
CORRECT …show more content…
A) "I am sorry, but what happened to your mother is confidential and I cannot give you any information."
The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions.
B) "Your mother has had a stroke, and the blood supply to the brain has been compromised."
The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail.
C) "How do you feel about what the healthcare provider said?"
The nurse should give facts first and then address her feelings after the information is provided.
D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition."
The nurse can, and should, address Gail's lack of knowledge.
Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I love my mom so much, and I am so scared. She is all I have."
How should the nurse respond?
A) "I am sure everything will be all right."
This response provides false reassurance and does not allow Gail to share her feelings.
B) "I know this is scary for you. Would you like to sit and talk?"
This therapeutic response provides acknowledgment of Gail's fears, and the nurse offers to take time to discuss the situation.
C) "I will notify