Question

A nurse is caring for a client in the emergency department (ED).

1000:
Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestations started about 30 mins ago. Client reports flashing lights in their vision, especially on the right side.
Client's partner states the client had some difficulty with finding words when speaking.
Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain.

Select the 4 findings that require follow-up by the nurse.

A. Orientation
B. Hand grasps
C. Visual disturbances
D. Expressive aphasia
E. Pain
F. Tingling of the lips
G. Blood pressure

Answer 1

The nurse should follow up on visual disturbances, expressive aphasia, hand grasps, and blood pressure.

Step-by-step explanation:

The nurse should follow up on the following findings:

• Visual disturbances - The client reported flashing lights in their vision, especially on the right side. This could indicate a potential issue with their visual system that requires further investigation.
• Expressive aphasia - The client had difficulty finding words when speaking, which suggests a problem with their language abilities. This should be assessed further.
• Hand grasps - The client's right hand grasp is weaker than their left, indicating a possible motor deficit that needs to be addressed.
• Blood pressure - The question does not provide any specific information about the client's blood pressure, so it cannot be determined if it requires follow-up.