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 A
Explanation
Choice A rationale:
Clients with obsessive-compulsive disorder (OCD) often benefit from maintaining control over their daily activities and schedules. Allowing the client autonomy in scheduling activities can help them manage their symptoms while feeling in control.
Choice B rationale:
Antipsychotic medications are not the first-line treatment for OCD, and their use would depend on the presence of other coexisting conditions.
Choice C rationale:
Providing ample time for rituals may inadvertently reinforce the compulsive behaviors associated with OCD. Cognitive-behavioral therapy (CBT) with exposure and response prevention is the recommended treatment for OCD.
Choice D rationale:
Implosion therapy, also known as flooding, exposes the client to anxiety-provoking stimuli in a controlled and safe environment. However, it is not typically the first-line treatment for OCD and requires careful implementation under the guidance of a mental health professional.
Correct Answer is A
Explanation
Choice A rationale:
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
Choice B rationale:
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
Choice C rationale:
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
Choice D rationale:
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
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