Question

A client who had a brain attack was admitted to the intensive care unit yesterday. The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking. What does the nurse do next?

a.Check the client's blood pressure and apical heart rate.
b.Elevate the back rest to 30 degrees and notify the health care provider.
c.Place the client in a supine position with a flat back rest, and observe.
d.Assess the client's white blood cell count and differential.

Answer 1

The nurse should elevate the back rest to 30 degrees and notify the healthcare provider immediately if a post-stroke patient becomes lethargic and has speech difficulties, as these could be signs of neurological deterioration.

Step-by-step explanation:

If a client who had a brain attack, also known as a stroke, becomes lethargic and unable to articulate words, the nurse should immediately elevate the back rest to 30 degrees and notify the healthcare provider. This position helps with breathing and potential swelling in the brain. The reduced articulation could indicate that the stroke has affected areas in the brain responsible for language, which may be worsening, and immediate medical attention is necessary. In addition to this, the healthcare provider should be informed so that necessary interventions, such as imaging or further medication, can be quickly implemented.