PN Adult Medical Surgical Practice Exam

Which of the following is the best initial action for a nurse when a client begins to exhibit signs of confusion after a stroke?

1. Administer prescribed sedatives.

2. Assess the client's vital signs for changes.

3. Call for a rapid response team.

4. Redirect the client's attention to a favorite activity.

The correct answer is: Assess the client's vital signs for changes.

In the scenario where a client begins to exhibit signs of confusion after a stroke, the best initial action is to assess the client's vital signs for changes. This choice is correct because vital signs provide critical information about the client’s current physiological state and can help identify any immediate complications or changes due to the stroke, such as altered consciousness or potential increases in intracranial pressure. Confusion after a stroke can result from various factors including, but not limited to, changes in blood pressure, oxygenation issues, or neurological deterioration. By assessing vital signs, the nurse can quickly determine if there are any urgent issues that need to be addressed. If vital signs indicate deterioration, timely interventions can be initiated. In contrast, administering prescribed sedatives may mask symptoms without addressing the underlying cause of confusion, and calling for a rapid response team could be necessary later, depending on the findings from the vital signs assessment. Redirecting the client's attention to a favorite activity may help manage confusion in a stable patient but does not address potential immediate physiological threats. Thus, monitoring vital signs is the foundational step in ensuring patient safety and effective care management.