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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Weight loss is not typically an expected manifestation following a total abdominal hysterectomy.
Choice B rationale:
Increased libido is not necessarily an expected manifestation following a total abdominal hysterectomy.
Choice C rationale:
Decreased menstrual bleeding is expected, as the uterus has been removed.
Choice D rationale:
Vaginal dryness is an expected manifestation following a total abdominal hysterectomy due to the removal of the ovaries, which produce hormones that contribute to vaginal lubrication.
Correct Answer is A
Explanation
Choice A rationale:
Dry mouth is a common side effect of amitriptyline, which is a tricyclic antidepressant. Informing the client of potential side effects is important for their understanding and management of medication-related symptoms.
Choice B rationale:
Amitriptyline is not known to cause an increase in blood pressure. In fact, it can have a hypotensive effect.
Choice C rationale:
Weight loss is not a typical side effect of amitriptyline. It can often lead to weight gain.
Choice D rationale:
Amitriptyline can cause urinary retention rather than increased urination.
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