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:
Epinephrine auto-injectors should be stored at room temperature and protected from light. Refrigeration is not recommended.
Choice B rationale:
The solution in an epinephrine auto-injector should be clear. If it appears discolored or contains particles, it may be expired or compromised.
Choice C rationale:
Epinephrine auto-injectors should not be shaken before use, as shaking could cause the solution to foam and result in inaccurate dosing.
Choice D rationale:
Holding the epinephrine auto-injector in place for 10 seconds allows the medication to be fully delivered into the muscle, enhancing its effectiveness.
Correct Answer is A
Explanation
Choice A rationale:
Avoiding temperature extremes can help prevent triggering a sickle cell crisis. Cold temperatures can cause blood vessels to constrict, leading to poor blood flow and increased risk of cell sickling.
Choice B rationale:
Engaging in high-impact exercise might not be recommended, as vigorous exercise can increase the risk of dehydration and oxygen deprivation, potentially triggering a crisis.
Choice C rationale:
Staying well-hydrated by drinking fluids is important, but temperature regulation is a key factor in preventing sickle cell crises.
Choice D rationale:
Receiving the influenza vaccine is recommended for individuals with sickle cell disease to reduce the risk of infections that could trigger a crisis. This statement is incorrect; the client should receive the influenza vaccine unless contraindicated.
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