A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

Start a labetalol drip to keep BP less than 140/90 mm Hg.

Keep the head of the bed elevated at least 30 degrees.

Begin tissue plasminogen activator (tPA) intravenously per protocol.

Infuse normal saline intravenously at 75 mL/hr.

Answer and Explanation

The Correct Answer is C

A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.

B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.

C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.

D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.

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Correct Answer is C

Explanation

A. Administer an oral analgesic: Administering analgesics may provide relief from pain, but it does not address the underlying cause of the headache and stiff neck. Assessing the client's neurological status is the priority to determine the severity and potential cause of the symptoms.

B. Perform a complete blood count: While laboratory tests may be necessary to further evaluate the client, they are not the first action to take when the client presents with symptoms suggestive of a neurological emergency such as meningitis. Assessing the client's neurological status and ruling out serious conditions take precedence.

C. Evaluate the client's neurological status: Assessing the client's neurological status, including level of consciousness, motor and sensory function, and signs of meningeal irritation (such as neck stiffness), is crucial for identifying potential neurological emergencies such as meningitis and guiding further management.

D. Check the client's temperature: While obtaining vital signs, including temperature, is important in the assessment of a client with suspected meningitis, it is not the first action to take. Assessing the client's neurological status and initiating appropriate interventions based on the findings are the priority.

A. BP 190/84, HR 50, and an irregular respiratory pattern B. BP 190/84, HR 150, and an irregular respiratory pattern C. BP 80/50, HR 50, and Kussmaul respirations D. BP 80/50, HR 150, and Cheyne-Stokes respirations

Correct Answer is A

Explanation

A. BP 190/84, HR 50, and an irregular respiratory pattern is characteristic of Cushing's triad, a classic sign of increased intracranial pressure (ICP). Cushing's triad includes hypertension with a widened pulse pressure, bradycardia, and irregular or abnormal respirations. The elevated blood pressure occurs as a compensatory mechanism to maintain cerebral perfusion, while bradycardia and irregular respirations result from brainstem compression.

B. BP 190/84, HR 150, and an irregular respiratory pattern is incorrect because tachycardia (HR 150) is not part of Cushing's triad. Increased ICP typically causes bradycardia due to brainstem involvement.

C. BP 80/50, HR 50, and Kussmaul respirations: Kussmaul respirations are deep, rapid respirations commonly seen in metabolic acidosis, not typically associated with increased intracranial pressure.
D. BP 80/50, HR 150, and Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of deep breathing followed by apnea and are often seen in conditions affecting the brainstem, but they are not specific to increased intracranial pressure.

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A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?

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