A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client?

Reasoning:

Choice A reason: Early mobilization post-ischemic stroke is critical during recovery to prevent complications like deep vein thrombosis, pneumonia, and muscle atrophy. It promotes neuroplasticity, improves circulation, and enhances functional recovery, making it a priority intervention in the immediate recovery period to optimize outcomes and reduce disability.

Choice B reason: Maximizing PaCO2 is not appropriate post-ischemic stroke. Elevated CO2 causes cerebral vasodilation, potentially increasing ICP, which is harmful. Maintaining normal CO2 levels supports cerebral perfusion without exacerbating edema, making this intervention irrelevant or potentially dangerous in stroke recovery.

Choice C reason: Positioning to avoid ICP is more relevant for hemorrhagic stroke, where ICP is a concern. In ischemic stroke, ICP is less likely unless severe edema occurs. Early mobilization takes precedence to prevent complications and promote recovery, making ICP positioning a secondary concern.

Choice D reason: Administering hypertonic IV solutions is used in cases of cerebral edema or elevated ICP, more common in hemorrhagic stroke. In ischemic stroke, hydration with isotonic fluids supports perfusion, but early mobilization is the priority to enhance recovery and prevent immobility-related complications.

Reasoning:

Choice A reason: Teaching coughing and deep breathing techniques prevents respiratory infections but is not the primary intervention for immune thrombocytopenia (ITP). ITP involves autoimmune platelet destruction, increasing bleeding risk. While infection prevention is important, maintaining platelet counts through transfusion is more critical to prevent hemorrhage in ITP.

Choice B reason: Giving aspirin to control temperature is contraindicated in ITP, as aspirin inhibits platelet function, worsening bleeding risk in clients with low platelet counts. Fever management should use alternative antipyretics like acetaminophen, making aspirin administration inappropriate and potentially harmful in this condition.

Choice C reason: Administering platelets, as ordered, is a key intervention in immune thrombocytopenia when bleeding risk is high. ITP causes autoimmune destruction of platelets, leading to thrombocytopenia. Platelet transfusions restore counts, reducing the risk of spontaneous bleeding, such as intracranial or gastrointestinal hemorrhage, a critical concern in severe cases.

Choice D reason: Administering stool softeners prevents straining, which could cause bleeding in ITP due to low platelets. While useful, it is secondary to platelet transfusion, which directly addresses the primary issue of thrombocytopenia and bleeding risk, making it less urgent than restoring platelet counts.