A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

The client should maintain systolic BP between 120 and 129 mm Hg.

The client should maintain systolic BP between 130 and 135 mm Hg.

The client should maintain systolic BP between 136 and 140 mm Hg.

The client should maintain systolic BP between 141 and 145 mm Hg.

Note the time the seizure started

Answer and Explanation

The Correct Answer is A

A. The client should maintain systolic BP between 120 and 129 mm Hg.

This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.

B. The client should maintain systolic BP between 130 and 135 mm Hg.

This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.

C. The client should maintain systolic BP between 136 and 140 mm Hg.

This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.

D. The client should maintain systolic BP between 141 and 145 mm Hg.

This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.

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Correct Answer is ["15"]

Explanation

To calculate the dose of phenytoin suspension, the nurse should use the following formula:

Dose (mL) = Desired dose (mg) / Concentration (mg/mL) x Volume (mL)

Plugging in the values from the question, we get:

Dose (mL) = 75 mg / (25 mg/5 mL) x 5 mL

Dose (mL) = 15 mL

Therefore, the nurse should administer 15 mL of phenytoin suspension to the patient

A. Instruct the client to perform controlled coughing and deep breathing. B. Provide a brightly lit environment. C. Elevate the head of the bed 30°. D. Encourage a minimum intake of 2,000 mL/day of clear fluids.

Correct Answer is C

Explanation

A. Instruct the client to perform controlled coughing and deep breathing.

This intervention is not appropriate for a client with increased intracranial pressure. Controlled coughing and deep breathing can increase intrathoracic pressure, which can in turn increase intracranial pressure. Therefore, this intervention should be avoided in clients with increased ICP.

B. Provide a brightly lit environment.

This intervention is not appropriate for a client with increased intracranial pressure. Bright lights can stimulate the reticular activating system and increase arousal, potentially exacerbating cerebral metabolic demand and intracranial pressure. Therefore, it is recommended to provide a calm, quiet environment with subdued lighting for clients with increased ICP.

C. Elevate the head of the bed 30°.

This intervention is correct. Elevating the head of the bed to 30 degrees promotes venous drainage from the head and reduces intracranial pressure. It helps prevent venous congestion in the brain and improves cerebral perfusion. This position is commonly used in clients with increased intracranial pressure to optimize cerebral blood flow.

D. Encourage a minimum intake of 2,000 mL/day of clear fluids.

This intervention is not appropriate for a client with increased intracranial pressure. While maintaining hydration is important for overall health, excessive fluid intake can increase intracranial pressure by increasing cerebral blood volume and cerebrospinal fluid production. Therefore, fluid intake should be carefully monitored and adjusted based on the client's condition and fluid balance.

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A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer phenytoin 75 mg PO. Available is phenytoin suspension 25 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["15"]

Explanation

A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions should the nurse take?

Correct Answer is C

Explanation

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