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. Placing the client with the head reclined back can increase the risk of aspiration and is not recommended.
B. Placing food in the affected side of the mouth could lead to choking, as the client may have reduced sensation or control on that side.
C. Encouraging the client to take small bites can help prevent choking and make swallowing easier.
D. While exercise might promote appetite, it is not directly related to feeding safety and should be discussed separately from swallowing instructions.

A. Paraplegia B. Paresthesia C. Quadriplegia D. Hemiplegia

Correct Answer is A

Explanation

A. Paraplegia: Paraplegia is the paralysis of the lower extremities and possibly the trunk, which can occur with a spinal cord injury at the level of the T2-T3 vertebrae.

B. Paresthesia: Paresthesia refers to abnormal sensations such as tingling or numbness and is not typically associated with a spinal cord injury at the T2-T3 level. It may occur with nerve damage but is not the primary disability anticipated in this scenario.

C. Quadriplegia: Quadriplegia, also known as tetraplegia, involves paralysis of all four limbs and the trunk. It is more commonly associated with injuries at higher levels of the spinal cord, such as cervical injuries.

D. Hemiplegia: Hemiplegia involves paralysis of one side of the body and is typically caused by a stroke or brain injury, not a spinal cord injury at the T2-T3 level.

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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

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