I would like to discuss this month's Challenge the School Nurse Question. For those of you who don't know NBCSN publishes a Challenge the School Nurse Question every month Sept.-June in School Nurse Digest and then it is published on our website, at the end of each year, we publish all 10 questions in our Challenge the School Nurse Archive.

One of our officers questioned this month's answer so I think it would be a good exercise to discuss the question here.

A teacher questions why they might be experiencing visual issues and a funny feeling in their face. The nurse's first action would be to *

A.    Activate EMS,

B.    Obtain vital signs,

C.    Advise he call his PCP,

D.    Ask if he takes any medication.

Please choose what you think is the correct answer and explain why it is correct. Also please explain why you think the other answers are incorrect.

Hello Pat,
D - Still need to gather more information (Assessing) 
Not A - Unless there is a serious breathing issue
Not B - You do this as you are collecting the more information
Not C - PCP would be a call that the parents should make under the advisement of the Nurse once all the information is collected and no life threating issues are in play

I will say I had already answered this question on the exam prep page - and I got it "wrong" I do agree with it being quesitoned.

I think it is to vague to choose A. Activate EMS. I chose B obtain vital signs. If an adult came to me and said they had blurred vision and their face "felt funny" (NOT drooping or slurred speech) I would definitely investigate more (quickly!) before calling EMS..  While taking their vitals I would be asking about their medications... they could have a hx of migraines or low blood sugar etc..  In that 3 minutes if I can't find a "good reason" for these symptoms then I would call 911 if the alert and oriented adult agreed (we can't make adults who are with it and capable of making decisions utilize 911) 

Sarah, This was my thought process, too....
I did end up choosing A - call EMS because better to be safe than sorry and while waiting for EMS to come, then I would take v/s, take medication history, etc...

HI Pat,
My answer would be B-Obtain vital signs. My reasoning is because the question asks for first "action". While doing so I would be asking about meds-D Then activate EMS if necessary

Hello,

I would choose C because it seems like there is no immediate danger but they need to reach out to their PCP asap for an evaluation, we could do an assessment but ultimately I think advising them the call their PCP is the most accurate. I think A is wrong because again the teacher is simply asking for advice, there is no indication that EMS is needed at this time. I think B is wrong because I think the teacher is not in distress and is only asking for advice, we could but we still have to refer them to their PCP, we can't diagnose. It is not D because although a nurse could do an assessment, I do not think it is warranted because this is a school setting, and unless it is an emergency we should stick with caring for the children and again we can not diagnose.

I think checking vital signs is correct only because it can give you some data even though it will not officially diagnose the problem itself.  Activating EMS would not be the first thing I did because this situation does not need immediate attention unless they would have a drooping face and if so then 911 would be called but since those details are not visible then calling 911 is not needed as of yet.  Calling the PCP and asking about medication is important would be what I would suggest after I did the vital signs and did not get any clearer picture of hat is going on.

Sorry I did not fully complete the question earlier, so I posted again and edited this one.

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Beverly Jordan MSN, RN, CSN
The School District of Philadelphia
Philadelphia, PA United States
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me too.

I would do the same.  

A. This teacher could be having a stroke so calling EMS would be the best answer.  
B. and D. Are obtaining more information  and assessing so they would cancel each other out. 

C. PCP would delay tx.
This was my first response. After reading the question for a second time I realized it was the teacher and not a student. I would be more concerned of stroke. 

Dear Pat,

I must admit I did not think this question (cut and pasted below) was straightforward. I chose answer B: "obtain vital signs as the answer". It was deemed wrong. 

However, my thinking was there "could be" many causes of "a funny feeling" to their face with visual issues. In fact I recently had an individual present with a "funny tingling feeling to their face and eye".  As we worked with the individual we learned they had an itchy scalp and say the first blisters erupting. The person was diagnosed later that day with shingles tracking the optic nerve. Definitely, a historical experience like this would not preclude the possibility the person in the scenario was having a stroke but I add this information to all the possible avenues that must be explored as the individual presents.

By getting a set of vital signs, I may identify hypertension, possibly see more symptoms such as weakness, pupil reaction abnormalities. I would continue assessing in case facial droop identified. All this information would be helpful should I contact EMS. Answers C and D could be relevant but would not be the "first" action. There is no mention of acute respiratory or cardiac decompensation which would necessitate immediate EMS activation. 

Bernadette Berset MSN, RN, NCSN

Question:

A teacher questions why they might be experiencing visual issues and a funny feeling in their face. The nurse's first action would be to *

A.    Activate EMS,

B.    Obtain vital signs,

C.    Advise he call his PCP,

D.    Ask if he takes any medication.

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Bernadette Berset, MSN, RN, NCSN
Certified School Nurse
Vienna, VA.
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I chose A.  The question indicated a couple of possible symptoms of stroke.
In the event of a stroke, the sooner they can get thrombolytics, the better, so I want to get them care immediately.
There is no VS finding that will rule out stroke, as there won't be a medication that they took that will rule out the possibility of stroke, so no matter what those showed, I'm inclined to activate EMS based on symptoms alone. Also -- the two choices of history/assessment were very closely related, so I thought those two could possibly be ruled out because they were so alike.

Let's keep asking about questions you don't understand. Make sure you are looking at the Rationale and References for questions you got wrong. Don't be afraid to discuss them.  That is how we all learn.

Now this question has garnered a lot of discussions. The first thing I would recommend if you get an answer wrong is to look at the rationale and the reference for the question. See if you can see why you might have gotten it incorrect,
So while this might not be the best question or at least many don't agree with it (34% got it correct - 66% got it incorrect (48% said take vital signs) if we look at the reference and rationale A is the correct answer.  This is probably the type of question that when it got to item reveiw might be edited or tossed.

A teacher questions why they might be experiencing visual issues and a funny feeling in their face. The nurse's first action would be to

A.    Activate EMS

B.    Obtain vital signs, 

C.    Advise he call his PCP,

D.    Ask if he takes any medication.

Rationale: Activation of 911 is essential in order to get treatment started as fast as possible.
Reference: https://www.cdc.gov/stroke/signs_symptoms.htm

Numbness or weakness in one side of the face, Vision problems in one or both eyes.

What are the signs of stroke in men and women?

• Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.
• Sudden confusion, trouble speaking, or difficulty understanding speech.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance, or lack of coordination.
• Sudden severe headache with no known cause.

Call 9-1-1 right away if you or someone else has any of these symptoms.

I would chose A on this as it is "the safest" response. However, the question in vague and in a real-life situation if this were to happen, I think I would honestly get vitals first. But for testing, I remember the safest answer is usually the correct answer. 

I would radio administration per policy then do B.  You need to have a baseline, something is wrong and possibilities need to be assess quickly. During assessing, meds can be asked about, and determine if EMS needs to be notified. If patient s/s don't progress, then would recommend to call Doctor for appointment.

Hi Pat,

I had to read this question a couple of times...

My answer is D The nurse's FIRST action is to ASSESS

Not A- Why? I still need more information. 

Not B-Why? I would do this but not the FIRST action.

Not C Why? After my assessment, and check their vital signs. I would still tell them to call their PCP and let their doctor know they are experiencing visual issues and having a funny feeling in their face. 

I got it wrong!😒

It doesn't say in the question that the teacher is having numbness in their face and trouble seeing. The question is vague. 

I would choose C, because you can get a base line and vitals can tell you alot, but prior to the vitals I would assess this was not an option. 

A - get 911. Delegate "you call 911" call from phone closest to health office staff and  "patient" 

B- NOT first , can get while waiting for EMS 

C- does not help or change outcome at this time. Of course event should be shared at some point. 
D- not first , ask about while waiting for EMS. EMS will ask patient if patient verbal when EMS arrives , may have staff emergency sheet on file that can be verified with staff while waiting for EMS. 

My first instinct was B - obtain vital signs. I always want more information to get a bigger picture, and I can do it really fast! I would simultaneously be asking questions as well as likely getting activating EMS. Don't the test question writers know that we are able to do at least 3 things at one time!?! :P

Good morning, All,

I would choose A due to visual changes (not clear cut Bells Palsy), ask what medications they take, take vital signs and explain they need a note to clearing them to return to school (ER discharge papers/PCP note).

BTW For Bells Palsy our Standing Orders are:

Facial Drooping Acute Onset
A. No 911 call if Under 35 yrs of age send to ER with parent/guardian to r/o Bells Palsy
B. If facial drooping/numbness travels or is associated with CP call 911 and notify
parent/guardian.
C. Do not give ASA to child
D. Ask about any recent immunizations, recent illness, tooth pain, tick or insect bite as well
(lymes is a common cause) or if on any medications.

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Christine Haines BSN, RN, CSN-NJ
School Nurse
Hammonton School District
Hammonton, [NJ] United States
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