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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While prothrombin level is an important test in evaluating blood clotting disorders, it is not typically used in the initial diagnostic evaluations for a cerebrovascular accident (CVA) or stroke.
Choice B rationale
Brain CT or MRI scans are commonly used in the initial diagnostic evaluations for a CVA. These imaging tests can show bleeding in the brain, an ischemic stroke, a tumor, or other conditions.
Choice C rationale
A chest x-ray is not typically used in the initial diagnostic evaluations for a CVA. It is more commonly used to diagnose conditions affecting the lungs and heart.
Choice D rationale
A lumbar puncture, or spinal tap, may be used in some cases to help diagnose a CVA, but it is not typically part of the initial diagnostic evaluations.
Correct Answer is A
Explanation
Choice A rationale
In the case of a major ischemic stroke, the medication that a nurse would anticipate the doctor to order is tissue plasminogen activator (tPA)8. This medication works by dissolving the clot that is blocking blood flow to the brain. It is most effective when given as soon as possible after the onset of stroke symptoms.
Choice B rationale
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain and reduce inflammation. It is not typically used in the treatment of ischemic stroke.
Choice C rationale
Aspirin is an antiplatelet drug that is sometimes used in the prevention of stroke. However, it is not typically used as an immediate treatment for a major ischemic stroke.
Choice D rationale
Warfarin is an anticoagulant medication that is used to prevent blood clots from forming or growing larger. It is not typically used as an immediate treatment for a major ischemic stroke.
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