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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Radiation therapy is not typically the primary method of treatment for melanoma. Surgical excision and other therapies are often utilized.
Choice B rationale:
Metastasis in melanoma generally occurs from the outer layers of the skin to deeper levels and eventually to other parts of the body.
Choice C rationale:
Specific genetic mutations, such as mutations in the BRAF gene, are associated with an increased risk of developing melanoma.
Choice D rationale: Melanoma is a highly metastatic form of skin cancer that can spread quickly to other parts of the body. Early diagnosis and treatment are crucial to improve outcomes.
Correct Answer is C
Explanation
Choice A rationale:
Shaking the auto-injector is not recommended as it could disrupt the medication's effectiveness. Epinephrine auto-injectors contain two separate components that need to be mixed upon injection.
Choice B rationale:
Massaging the injection site after using the auto-injector can actually help disperse the medication and promote absorption and reduce pain and swelling.
Choice C rationale:
Injecting the medication into the top of the thigh is the correct administration site and technique for an epinephrine auto-injector. It's a large muscle area that allows for rapid absorption.
Choice D rationale:
Epinephrine auto-injectors should not be refrigerated, as extreme temperatures can affect their functionality. The client should store the device at room temperature away from light and heat sources.
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