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:
Requesting an opportunity to discuss trauma might be indicative of the client's desire to process their experiences, but it's not a specific symptom of PTSD.
Choice B rationale:
Recurrent nightmares are a common symptom of PTSD, often related to the traumatic event.
Choice C rationale:
Indicating working extra hours is not a specific symptom of PTSD.
Choice D rationale:
Exhibiting diminished reflexes is not a typical symptom of PTSD.
Correct Answer is B
Explanation
Choice A rationale:
A positive Rheumatoid factor is associated with rheumatoid arthritis and is not an adverse effect of methotrexate.
Choice B rationale:
A low WBC count (leukopenia) is an adverse effect of methotrexate and can increase the risk of infection.
Choice C rationale:
A hemoglobin level of 14.8 g/dL is within a normal range and is not an adverse effect of methotrexate.
Choice D rationale:
An erythrocyte sedimentation rate (ESR) of 24 mm/hr is within a normal range and is not an adverse effect of methotrexate.
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