The nurse is caring for a patient recovering from an ischemic stroke.
What intervention best addresses a potential complication after an ischemic stroke?

Keep a urinary catheter in place for the entire duration of recovery.

Provide three larger meals rather than frequent small meals.

Limit the intake of insoluble fiber.

Teach the patient to perform deep breathing and coughing exercises.

Answer and Explanation

The Correct Answer is D

Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.

Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.

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Correct Answer is A

Explanation

Choice A rationale
Triptans, a class of medications commonly used to treat migraines, can cause vasoconstriction, or narrowing of the blood vessels. This can be problematic for patients with angina, a condition characterized by reduced blood flow to the heart. Vasoconstriction could potentially exacerbate this condition, leading to an increased risk of a heart attack. Therefore, the use of triptans may be contraindicated in patients with angina.

Choice B rationale
While asthma is a serious condition that requires careful management, it is not typically considered a contraindication for the use of triptans. Triptans work primarily on the blood vessels in the brain and do not typically interact with the bronchial tubes affected by asthma.
Choice C rationale
Age alone is not typically a contraindication for the use of triptans. However, older adults may have a higher risk of certain health conditions, such as heart disease, which could make the use of triptans more risky. It’s important for healthcare providers to consider the overall health status of the patient, not just their age, when deciding whether to prescribe triptans.
Choice D rationale
While stress can certainly exacerbate migraines, it is not typically a contraindication for the use of triptans. Triptans are designed to relieve the pain and other symptoms of migraines, regardless of their cause. If a patient’s migraines are triggered by stress, it may be beneficial to explore stress management techniques in addition to medication.

A. Arrange for the client to have visual acuity assessed. B. Facilitate tonometry testing C. Arrange for the client to be assessed for macular degeneration. D. Reassure the client that this is an age-related change in vision.

Correct Answer is C

Explanation

Choice A rationale
While assessing visual acuity may be part of a comprehensive eye examination, it would not specifically address distortions noted on the Amsler grid.
Choice B rationale
Tonometry testing is used to measure the pressure inside the eye and is typically used in the diagnosis of glaucoma. It would not specifically address distortions noted on the Amsler grid.
Choice C rationale
Distortions when looking at the Amsler grid can be a sign of macular degeneration16. Therefore, arranging for the client to be assessed for macular degeneration would be the appropriate action16.
Choice D rationale
While age-related changes in vision can occur, distortions when looking at the Amsler grid are not typically considered a normal age-related change16. Therefore, reassuring the client that this is an age-related change in vision would not be the appropriate action16.

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The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a recent history of migraines. What aspect of this patient’s current status may contraindicate the safe use of triptans?

Correct Answer is A

Explanation

A client has informed the Home Health Nurse that they recently noticed distortions when looking at the Amsler grid kept on their refrigerator. What is the appropriate action for the nurse to take?

Correct Answer is C

Explanation

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

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The nurse is caring for a patient recovering from an ischemic stroke.
What intervention best addresses a potential complication after an ischemic stroke?