A nurse is planning care for a client who has ischemic stroke and is at risk for cerebral edema. Which of the following interventions should the nurse include in the plan?

Elevate the head of the bed to 30 degrees.

Administer mannitol as prescribed.

Monitor the client's intracranial pressure.

All of the above.

Answer and Explanation

The Correct Answer is D

Choice A reason:

This is correct because elevating the head of the bed to 30 degrees can help reduce intracranial pressure by facilitating venous drainage and decreasing cerebral blood volume.

Choice B reason:

This is correct because administering mannitol as prescribed can help reduce intracranial pressure by creating an osmotic gradient that draws fluid out of the brain tissue and into the bloodstream.

Choice C reason:

This is correct because monitoring the client's intracranial pressure can help detect any signs of increased intracranial pressure or cerebral herniation, which can be life-threatening complications of cerebral edema.

Choice D reason:

This is correct because all of the above interventions are appropriate for a client who has ischemic stroke and is at risk for cerebral edema.

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Correct Answer is D

Explanation

Choice A reason:

This is a correct statement, as the CNS receives sensory information from various receptors in the body and interprets it.

Choice B reason:

This is a correct statement, as the CNS initiates and coordinates motor commands to control voluntary and involuntary movements.

Choice C reason:

This is a correct statement, as the CNS is involved in higher cognitive functions such as memory, learning, reasoning, and emotions.

Choice D reason:

This is an incorrect statement, as this is the function of the PNS. The PNS consists of cranial and spinal nerves that connect the CNS to the rest of the body and transmit sensory and motor signals.

A. Monitor the client's vital signs and neurological status frequently. B. Administer rtPA within 4.5 hours of symptom onset. C. Maintain the client's systolic blood pressure below 180 mm Hg. D. Give aspirin or other antiplatelet agents along with rtPA. E. Assess the client for signs of bleeding or hemorrhagic transformation.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:
This is correct because monitoring the client's vital signs and neurological status frequently can help detect any changes in the client's condition, such as improvement or deterioration of symptoms, or complications such as bleeding or increased intracranial pressure.

Choice B reason:
This is correct because administering rtPA within 4.5 hours of symptom onset can increase the chances of restoring blood flow to the ischemic brain tissue and reducing neurological damage. The effectiveness and safety of rtPA decrease after this time window.

Choice C reason:
This is correct because maintaining the client's systolic blood pressure below 180 mm Hg can prevent further ischemia or hemorrhage in the brain. High blood pressure can increase the risk of bleeding or reperfusion injury after thrombolytic therapy.

Choice D reason:
This is incorrect because giving aspirin or other antiplatelet agents along with rtPA can increase the risk of bleeding or hemorrhagic transformation. Antiplatelet agents should be avoided for at least 24 hours after thrombolytic therapy.

Choice E reason:
This is correct because assessing the client for signs of bleeding or hemorrhagic transformation can help identify any adverse effects of thrombolytic therapy. Bleeding or hemorrhagic transformation can manifest as hematuria, hematemesis, melena, petechiae, ecchymosis, epistaxis, gingival bleeding, headache, altered mental status, or worsening neurological deficits.

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A nurse is planning care for a client who has ischemic stroke and is at risk for cerebral edema. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about the functions of the central nervous system (CNS). Which of the following statements by the client indicates a need for further teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has ischemic stroke and is receiving thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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