Which statement is accurate about the recommendations for BP management after an ischemic stroke?

The BP must be lower than 130/70 mm Hg to receive fibrinolytic agents.

Elevated BPs are expected after a stroke, and drug therapy should be initiated.

A lower BP is a protective response to maintain cerebral perfusion.

Drugs to lower BP are recommended if the BP is 220/120 mm Hg or higher

Answer and Explanation

The Correct Answer is D

A.   The BP must be lower than 180/105 mm Hg to receive fibrinolytic agents, not 130/70 mm Hg.
B.   Elevated BPs are common immediately after a stroke, but drug therapy to lower BP is not initiated unless it reaches high levels (typically > 220/120 mm Hg).
C.   A lower BP does not act as a protective response; maintaining a higher BP can be necessary initially after a stroke to ensure adequate cerebral perfusion.

D.   If BP is 220/120 mm Hg or higher after ischemic stroke, aggressive antihypertensive therapy is initiated to reduce the risk of hemorrhagic transformation and other complications.

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Correct Answer is []

Explanation

Increased Intracranial Pressure (ICP)

Based on the patient’s clinical presentation, which includes a fall, slurred speech, weak cough reflex, restlessness, and a slight headache, the patient is at risk for increased intracranial pressure (ICP). The history of falling from a ladder could suggest a possible head injury, and the changes in speech and restlessness could be early signs of increasing ICP. The presence of a laceration on the left temple may also indicate a traumatic brain injury, which is a key risk factor for increased ICP.

Actions to Take:

Apply oxygen via cannula at 2 L/min

Oxygen is critical for brain tissue oxygenation, especially in patients with possible head injuries and ICP. The patient's oxygen saturation is 90% on room air, which is slightly low and requires supplementation to maintain adequate oxygen levels and reduce the risk of hypoxia, which can exacerbate increased ICP.

Elevate the head of the bed to 45 degrees

Elevating the head of the bed to 30-45 degrees can help improve venous drainage from the brain, thus reducing the risk of increased ICP. Positioning the patient in this way also helps reduce pressure on the brain and enhances cerebral perfusion.

Parameters to Monitor:

Level of consciousness (LOC)

Changes in the patient's level of consciousness are a key indicator of worsening ICP. The nurse should assess the patient’s alertness, orientation, and any deterioration in cognitive function or responsiveness. The patient's current orientation level is X2, meaning they are only oriented to person and place, which may signal a developing problem.

Vital signs

Monitoring vital signs, especially blood pressure, heart rate, and respiratory rate, is crucial in assessing the patient's neurological status. Changes in blood pressure (especially widening pulse pressure) or abnormal respiratory patterns can be early indicators of increased ICP. In particular, the patient's blood pressure (152/59) suggests a possible increased risk of ICP, with the systolic value elevated but the diastolic pressure relatively low. This could be a compensatory response to ICP or another issue.

A. Unable to discriminate words and letters B. Deficits in the right visual field C. Motor retardation D. Poor impulse control

Correct Answer is D

Explanation

A. Unable to discriminate words and letters is associated with left hemisphere damage, which is more linked to language and communication deficits.
B. Deficits in the right visual field would typically occur with left hemisphere damage, which affects vision.
C. Motor retardation is more often associated with left hemisphere damage affecting motor control.
D. Right cerebral hemisphere damage often results in behavioral changes, such as poor impulse control, lack of awareness of deficits (anosognosia), and changes in emotional responses.

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Which statement is accurate about the recommendations for BP management after an ischemic stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Increased Intracranial Pressure (ICP)

Actions to Take:

Parameters to Monitor:

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is D

Explanation

Which intervention would the nurse implement to provide relief of the patient's discomfort when presenting to the clinic with a red, swollen, circumscribed, acutely, tender area near the eye and in the lid margin?

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective?

If blood flow to the brain is interrupted, how quickly does cellular death occur?

Which initial clinical manifestation would a patient report with a retinal detachment?

Which visual disorder would the nurse associate with the patient's clinical manifestations of itching, irritation, intolerance of light, and crusty debris of the lid margins and lashes?

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings?

Which refractive error describes the vision of a patient for whom nearby objects are clear but objects at a distance are blurred?

A nurse observes a patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression?