A patient develops sudden facial drooping and weakness of the right arm while eating breakfast. The patient is awake and breathing normally. What should the nurse do first?
Correct answer: B. Activate the urgent stroke response pathway
- A. Give the patient water to assess swallowing
- B. Activate the urgent stroke response pathway
- C. Ask the patient to rest and reassess later
- D. Administer the prescribed oral analgesic
Explanation
Sudden focal neurological changes suggest an acute stroke and require immediate activation of the stroke response pathway. The nurse should not give food or fluids until swallowing safety is assessed, because dysphagia and aspiration may occur.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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50 free Clinical Judgement and Prioritisation MCQs from International Nursing Practice, each with the correct answer and an explanation. Unlimited attempts, no account needed.
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