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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Replacing the ritual with a different ritualistic behavior is possible, but it does not necessarily predict the initial response when the restriction is first imposed.

Choice B rationale:

Reporting auditory hallucinations is not a typical response to restricting ritualistic behavior in someone with OCD.

Choice C rationale:

Expressing relief from not having to perform the ritual is unlikely, as ritualistic behaviors in OCD are often driven by distress and anxiety.

Choice D rationale:

If ritualistic behavior is restricted in an individual with obsessive- compulsive disorder (OCD), they may experience panic-level anxiety due to their inability to engage in their usual coping mechanism. OCD rituals are often performed to reduce anxiety, and restricting them can lead to increased distress.

A. Allow the client extra time to perform ADLS. B. Monitor the client for weight gain. C. Instruct the client to look down at the feet when walking. D. Provide the client with a low-protein diet.

Correct Answer is A

Explanation

Choice A rationale:

Clients with Parkinson's disease often have motor difficulties and slowed movements. Allowing extra time for activities of daily living (ADLs) can help them maintain independence and reduce frustration.

Choice B rationale:

Weight gain is not a common manifestation of Parkinson's disease or a primary concern in its management.

Choice C rationale:

Instructing the client to look down at the feet when walking is not accurate advice for Parkinson's disease. It's important to maintain an upright posture and look ahead to improve balance and gait.

Choice D rationale:

A low-protein diet is not generally recommended for clients with Parkinson's disease, as protein can affect the absorption of levodopa, a common medication used in its management.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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