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 D
Explanation
Choice A rationale:
Rhinorrhea is not a common adverse effect of baclofen.
Choice B rationale:
Hirsutism (excessive hair growth) is not a common adverse effect of baclofen.
Choice C rationale:
Tachycardia is not a common adverse effect of baclofen.
Choice D rationale:
Constipation is a common adverse effect of baclofen. Baclofen is a muscle relaxant that can affect the gastrointestinal system, leading to reduced bowel motility and constipation.
Correct Answer is C
Explanation
Choice A rationale:
Scheduling appointments earlier in the day accommodates the client's potential "on" periods when Parkinson's symptoms are better controlled.
Choice B rationale:
Looking down at the feet while walking is a technique that can help improve gait and stability, as Parkinson's disease often affects balance.
Choice C rationale:
Thicker liquids are less likely to cause aspiration in individuals with Parkinson's disease, as they can have difficulty coordinating the muscles needed for swallowing.
Choice D rationale:
Constipation is a common issue in Parkinson's disease due to decreased gastrointestinal motility. However, focusing on dietary fiber and fluid intake is preferred before considering laxatives.
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.