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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Comfrey is not commonly recommended as an herbal supplement for menopausal symptoms. It has been associated with potential liver toxicity.
Choice B rationale:
Ginkgo biloba is often used to improve cognitive function and circulation but is not typically used to address menopausal symptoms.
Choice C rationale:
Black cohosh is an herbal supplement that is commonly used by middle-aged women to help alleviate symptoms related to menopause, such as hot flashes and mood swings. Black cohosh may also have some benefits for bone health and cardiovascular health. However, black cohosh may also have some side effects and interactions with other medications, so the nurse should advise the women to consult their health care providers before taking it.
Choice D rationale:
Garlic is not typically used as an herbal supplement to manage menopausal symptoms; it is more commonly known for its potential cardiovascular benefits.
Correct Answer is D
Explanation
Choice A rationale:
Monitoring for hearing loss is not a specific action for primary syphilis. Hearing loss can occur in later stages of syphilis.
Choice B rationale:
Contact precautions are not typically required for primary syphilis, as it is primarily transmitted through sexual contact.
Choice C rationale:
Antiviral medications are not used to treat syphilis. Antibiotics are the primary treatment.
Choice D rationale:
Syphilis is a sexually transmitted infection that is required to be reported to the public health department for tracking and control.
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