A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?

A client who has an arteriovenous malformation

A client who has thrombocytopenia

A client who has chronic atrial fibrillation

A client who has uncontrolled hypertension

Answer and Explanation

The Correct Answer is C

A client who has chronic atrial fibrillation is at risk for an ischemic embolic stroke. An ischemic embolic stroke occurs when a blood clot that forms in one part of the body travels to the brain and blocks blood ﬂow. Atrial fibrillation is a type of irregular heart rhythm that can cause blood to pool, thicken, and clot in the heart or arteries near it. Pieces of these clots can travel to the brain and cause an ischemic embolic stroke.

a. A client who has an arteriovenous malformation is not at risk for an ischemic embolic stroke.
b. A client who has thrombocytopenia is not at risk for an ischemic embolic stroke.
d. A client who has uncontrolled hypertension is at risk for a stroke but not specifically an ischemic embolic
stroke.

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Correct Answer is D

Explanation

An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.

The client is not unconscious, as a GCS score of 3 for eye opening indicates that the client is able to open his eyes in response to voice. The client is not unable to make vocal sound, as a GCS score of 5 for best verbal response indicates that the client is able to make vocal sounds. The client may or may not be able to follow simple motor commands, as a GCS score of 5 for best motor response indicates that the client is able to localize pain.

A. Apply a compression bandage to the client's ankle. B. Apply heat to the client's ankle. C. Encourage range of motion of the client's foot. D. Elevate the client's foot. E. Check the client's toes for color, temperature, and sensation.

Correct Answer is ["A","D","E"]

Explanation

These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.

Applying heat to the client's ankle is not recommended as it can increase swelling and inﬂammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the aﬀected area.

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A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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