Which of the following is a priority nursing intervention for a client admitted with an ischemic stroke?
Position the client in semi-Fowler’s for optimal respiratory function
Put the client in mild Trendelenburg position to decrease hypertension
Place the client flat for 24 hours to decrease cerebral ischemia
Raise the head of the bed 30 degrees for cerebral perfusion
The Correct Answer is D
Choice A reason: Semi-Fowler’s aids breathing but doesn’t optimize cerebral blood flow, critical in ischemic stroke to perfuse brain tissue, less urgent than perfusion.
Choice B reason: Trendelenburg lowers the head, risking increased intracranial pressure in stroke, not reducing hypertension effectively, contraindicated for cerebral ischemia.
Choice C reason: Flat positioning may increase intracranial pressure, worsening ischemia; elevation enhances perfusion, so keeping flat isn’t the priority intervention.
Choice D reason: Raising the head 30 degrees improves cerebral perfusion by balancing blood flow and reducing pressure, the priority to minimize ischemic damage.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Dressing involves both sides but can be adapted with the left hand; right-sided CVA impairs left-side function, less affecting dominant right-hand tasks.
Choice B reason: Writing, a fine motor skill, relies on the dominant right hand, controlled by the left brain; right-sided CVA disrupts this, making it most difficult.
Choice C reason: Combing hair uses gross motor skills, manageable with the left hand despite right-sided CVA’s left-sided weakness, less challenging than writing.
Choice D reason: Eating uses the right hand but can be adjusted with utensils or left-hand assistance; it’s less precise than writing, so less impacted.
Correct Answer is A
Explanation
Choice A reason: Donepezil treats Alzheimer’s by inhibiting cholinesterase, boosting acetylcholine for cognition. Lupus, an autoimmune disease, doesn’t involve dementia primarily, so this drug lacks relevance to its management.
Choice B reason: Prednisone, a corticosteroid, suppresses inflammation and immune response in lupus, reducing joint pain and organ damage from autoantibody activity, making it a standard treatment.
Choice C reason: Hydroxychloroquine modulates immunity and reduces lupus flares by stabilizing lysosomes and decreasing autoantibody production, directly addressing its autoimmune pathology.
Choice D reason: Methotrexate, an immunosuppressant, inhibits folate metabolism, curbing immune cell proliferation in lupus, effectively managing severe symptoms like arthritis or organ involvement.
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