A nurse assesses a patient who suddenly develops facial drooping and weakness of the right arm. What is the priority action?
Correct answer: C. Report the acute findings immediately according to emergency policy
- A. Document the findings at the end of the shift
- B. Offer oral fluids and ask the patient to rest
- C. Report the acute findings immediately according to emergency policy
- D. Wait for the next routine medical round before reporting
Explanation
Sudden facial drooping and arm weakness may indicate an acute stroke and require immediate reporting for time-sensitive assessment and treatment. Delaying for documentation or a routine round places patient safety at risk.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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