A nurse is caring for a client who was admitted following an ischemic stroke. Which of the following actions should the nurse take? (Select all that apply.)
Provide rest breaks between nursing care activities.
Notify the provider of a systolic BP higher than 180 mm Hg.
Administer aspirin 650 mg every 6 hr for a headache.
Keep the client's head in a midline neutral position.
Monitor the client's vital signs every 4 hr
Correct Answer : A,B,D,E
A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.
B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.
C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.
D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.
E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
Correct Answer is D
Explanation
Choice A rationale:
Holding the fork through the entire meal can lead to mindless eating and overeating. The client should put down the fork between bites and chew slowly to savor the food and feel full faster.
Choice B rationale:
Planning meals day by day can be stressful and impractical for the client. The client might not have enough time or resources to prepare healthy meals every day, or might be tempted by unhealthy options when hungry. The client should plan meals ahead of time, such as weekly or monthly, and stock up on nutritious foods that are easy to prepare.
Choice C rationale:
Scheduling three times to eat each day can be too rigid and unrealistic for the client. The client might not feel hungry at the scheduled times, or might feel hungry in between meals and snack
on junk food. The client should listen to their body and eat when they are hungry, but not too hungry. The client should also eat slowly and stop when they are full, but not too full.
Choice D rationale:
Eating off a smaller plate can help reduce the portion size and calorie intake of the client. This is a simple and effective way to manage obesity without feeling deprived or hungry. A smaller plate can also create an illusion of having more food, which can increase the satisfaction of the meal.
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