A client with an ischemic stroke has right-sided weakness and slurred speech.
Which complication should the nurse prioritize monitoring for in the first 24 hours?
Aspiration.
Urinary retention.
Contractures.
Depression.
The Correct Answer is A
Acute neurological deficits following a stroke increase the risk of secondary complications. Knowledge of cranial nerve involvement and protective reflexes is vital. The nurse must prioritize airway and respiratory safety within the critical 24 hour post ischemic event window.
Choice A rationale
Right sided weakness often includes the facial and pharyngeal muscles, impairing the gag reflex and swallowing. This increases the risk of food or secretions entering the lungs, leading to pneumonia or acute respiratory distress during recovery.
Choice B rationale
While urinary retention can occur after a stroke due to neurogenic bladder or immobility, it is not an immediate life threat. It requires monitoring and management but takes lower priority than ensuring the client maintains a patent airway.
Choice C rationale
Contractures are a long term complication of immobility and muscle spasticity following a stroke. While range of motion exercises are important for rehabilitation, they are not a priority during the first 24 hours of acute stabilization.
Choice D rationale
Depression is a common psychological consequence of the lifestyle changes and deficits caused by a stroke. However, psychological assessment occurs later in the care plan after the client is physiologically stable and out of danger.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Immediate first aid for thermal burns focuses on stopping the burning process and limiting tissue damage. This scenario requires applying knowledge of cooling mechanisms to dissipate heat from deep tissue layers without causing further vasoconstriction or injury.
Choice A rationale
Cool tap water helps dissipate heat from the skin and prevents the burn from progressing to deeper layers. Applying cool water for twenty minutes reduces edema and provides immediate pain relief without causing thermal shock.
Choice B rationale
Ice packs should never be applied directly to a burn. Extreme cold causes profound vasoconstriction, which impairs local blood flow to the injured area and can lead to frostbite or further tissue necrosis and ischemia.
Choice C rationale
While medical evaluation is necessary for serious burns, immediate cooling is the priority to stop tissue destruction. Delaying first aid to travel to a doctor without cooling the hand first allows the heat to continue.
Choice D rationale
Ointments or butter can trap heat within the skin and increase the risk of infection. Professional assessment should occur before applying topical agents, as they can interfere with the initial cleaning and debridement of the wound.
Correct Answer is C
Explanation
Management of hypertensive crisis involves using calcium channel blockers to achieve rapid vascular relaxation. Knowledge of pharmacodynamics is necessary to explain how nicardipine reduces systemic vascular resistance to mitigate the risk of cerebrovascular accidents and end organ damage in emergencies.
Choice A rationale
Nicardipine is a dihydropyridine calcium channel blocker that primarily causes vasodilation. It does not act as a positive chronotrope. Increasing heart rate in a hypertensive crisis could dangerously increase myocardial oxygen demand and exacerbate the clinical situation.
Choice B rationale
The medication does not possess analgesic properties or stimulate endorphin release. While the headache may improve as intracranial pressure decreases from lowered blood pressure, the primary pharmacological mechanism is vascular smooth muscle relaxation rather than pain modulation.
Choice C rationale
Nicardipine inhibits calcium ion influx into vascular smooth muscle, leading to rapid peripheral vasodilation. In a hypertensive emergency (BP > 180/120 mm Hg), quick reduction is critical to prevent intracranial hemorrhage, encephalopathy, or ischemic stroke.
Choice D rationale
Nicardipine does not function as a diuretic. While lowering blood pressure reduces renal strain, it does not promote fluid loss through the kidneys. Diuretics like furosemide are separate agents used for volume related hypertension or edema.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.