A nurse is caring for a client who was admitted following an ischemic stroke. Which of the following actions should the nurse take? (Select all that apply.)
Provide rest breaks between nursing care activities.
Notify the provider of a systolic BP higher than 180 mm Hg.
Administer aspirin 650 mg every 6 hr for a headache.
Keep the client's head in a midline neutral position.
Monitor the client's vital signs every 4 hr
Correct Answer : A,B,D,E
A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.
B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.
C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.
D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.
E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.
B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.
C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.
D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.
E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.
Correct Answer is A
Explanation
Choice A rationale:
Children with autism spectrum disorder often have difficulty with transitions and new situations. Introducing new situations slowly can help reduce anxiety and support a smoother adjustment.
Choice B rationale:
Administering valproic acid is not a nursing intervention for autism spectrum disorder.
Choice C rationale:
Allowing the toddler to choose the daily routine might not be effective as they may struggle with decision-making and may prefer structured routines.
Choice D rationale:
Increasing stimulation in the toddler's environment might overwhelm a child with autism, who often prefers a calm and predictable environment.
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