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A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?

Limit suctioning the client's airway to 30 seconds at a time

Group several nursing activities to be completed at one time

Flex the client's neck forward

Place the client in a quiet environment

Answer and Explanation

The Correct Answer is D

Place the client in a quiet environment.

A. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.
B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate. Therefore, this choice is incorrect.
C. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.
D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.

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Correct Answer is B

Explanation

Choice A rationale:

Assisted living facilities are suitable for individuals who need assistance with activities of daily living but do not require skilled nursing care. This option might not be necessary based on the partner's exhaustion alone.

Choice B rationale:

Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. Given the partner's exhaustion, respite care would offer the much-needed rest, reducing caregiver burnout and ensuring better care for the client at home.

Choice C rationale:

Rehabilitation services are designed for patients who need specialized therapy after an illness or injury. While they might be beneficial for the client following a stroke, they do not directly address the partner's exhaustion and need for relief.

Choice D rationale:

Skilled nursing facilities provide 24/7 medical care for individuals with complex medical needs. The partner's exhaustion does not necessarily indicate the need for skilled nursing care, as the client's condition and care requirements were not provided in the scenario.

A. "I will take the medication in the morning.” B. "I will expect to gain weight.” C. "I will take the medication on an empty stomach.” D. "I will avoid crushing this medication.”

Correct Answer is D

Explanation

Choice A rationale:

The statement, "I will take the medication in the morning," indicates lack of understanding. Metformin is usually taken with large meals, and taking it in the morning is not the best timing.

Choice B rationale:

The statement, "I will expect to gain weight," is incorrect. Weight gain is not an expected side effect of metformin. In fact, metformin is often associated with weight loss or weight maintenance, especially in individuals with diabetes, as it helps improve insulin sensitivity and glucose metabolism.

Choice C rationale:

The statement, "I will take the medication on an empty stomach," is incorrect for extended-release metformin tablets. Unlike immediate-release metformin, extended-release tablets should be taken with meals to reduce the risk of gastrointestinal side effects.

Choice D rationale:

The statement, "I will avoid crushing this medication," is correct. Metformin extended-release tablets should never be crushed or broken, as it can affect the way the medication is released into the body. Crushing or breaking the tablet can lead to a sudden release of a large amount of metformin, potentially causing an overdose.

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A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A case manager is performing a home visit for a client following a stroke.The client's partner is providing care in the home.The client's partner states that she sometimes feels exhausted.Which of the following referrals should the case manager recommend for the caregiver?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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