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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Bradykinesia: Bradykinesia refers to slowness of movement and is commonly associated with Parkinson's disease. It is not typically assessed through neck flexion in the context of meningitis.

B. Kernig's sign: Kernig's sign is assessed by flexing the patient's hip and knee and then attempting to extend the knee. Resistance or pain during knee extension suggests meningeal irritation, but it does not involve the involuntary flexion of the legs.

C. Nuchal rigidity: Nuchal rigidity refers to stiffness and pain in the neck and inability to flex the neck forward due to inflammation of the meninges. While it is related to meningitis, it does not involve involuntary flexion of the legs.

D. Brudzinski's sign: Brudzinski's sign is a physical exam finding where passive flexion of the neck results in involuntary flexion of the hips and knees. It is a classic sign of meningeal irritation, often seen in meningitis.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse and address the clients right shoulder pain after addressing the clients drowsiness. a clients recovery can be affected by pain by inhibiting their ability to become active and involved in self-care. The goal is to provide pain relief so that the client is able to participate in the recovery and to improve the clients functional status. Assessment of paint should include intensity, quality, duration, and location.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Correct Answer is D

Explanation

A nurse is caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder. Exhibits Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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