The nurse is caring for a client with a history of liver cirrhosis. Which complication should the nurse monitor for?

Choice A reason: Administering aspirin is appropriate for ischemic stroke but premature without confirming stroke type. Hemorrhagic stroke contraindicates aspirin. A head CT scan distinguishes ischemic from hemorrhagic stroke, guiding treatment, making it the priority to ensure safe intervention.

Choice B reason: Obtaining a head CT scan is the priority, as it differentiates ischemic from hemorrhagic stroke, critical for guiding treatment like thrombolytics or anticoagulation. Rapid imaging within the therapeutic window ensures timely intervention, minimizing brain damage, making it the essential first step.

Choice C reason: Monitoring blood glucose is important, as hyperglycemia worsens stroke outcomes, but it is secondary to confirming stroke type. A head CT scan provides diagnostic clarity, guiding urgent therapy, making imaging the priority over metabolic assessments in suspected stroke.

Choice D reason: Elevating the head of the bed reduces intracranial pressure but is not the first step. A head CT scan confirms stroke type, ensuring appropriate interventions like thrombolytics for ischemic stroke, making imaging critical to guide management and prevent further brain injury.

Choice A reason: A foreign body in the eye may cause irritation or damage but is not a contraindication for ketorolac, a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. The nurse would ensure removal of the foreign body first, but ketorolac can be used post-removal if indicated.

Choice B reason: Radiation exposure, such as from UV light, may cause photokeratitis but is not a specific contraindication for ophthalmic ketorolac. The medication reduces inflammation and pain, which may be beneficial in such cases. The nurse should assess for other ocular conditions, but radiation exposure alone does not preclude its use.

Choice C reason: Chemical burns require immediate irrigation and specific treatments based on the chemical involved. Ketorolac may reduce pain and inflammation post-irrigation, but it is not contraindicated. The nurse should prioritize burn management, but chemical burns do not inherently prohibit ketorolac use compared to corneal abrasions.

Choice D reason: Corneal abrasions are a contraindication for ophthalmic ketorolac, as NSAIDs can delay corneal healing and increase the risk of complications like corneal ulceration. The nurse must review the medical record to confirm the absence of abrasions, as ketorolac is typically used for postoperative pain, not traumatic corneal injuries.