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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.

Choice B rationale:

Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.

Choice C rationale:

Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.

Choice D rationale:

Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.

A. "I feel guilty that my fellow soldiers died in combat and I survived." B. "I keep having flashbacks about when I was attacked by my neighbor." C. "I prefer to go through the recovery process independently." D. "I think my experience has affected my ability to trust others."

Correct Answer is B

Explanation

Choice A rationale:

Expressing feelings of guilt and survivor's guilt is a common aspect of processing traumatic experiences and can be an important step in healing.

Choice B rationale:

Rationale: This statement indicates that the client is acknowledging and discussing the flashbacks related to the traumatic event. Progression toward positive outcomes in posttraumatic stress disorder (PTSD) often involves recognizing and addressing distressing symptoms.

Choice C rationale:

The preference for independence may indicate resistance to seeking support, which can hinder progress in addressing and managing PTSD symptoms.

Choice D rationale:

Recognizing that the traumatic experience has affected the ability to trust others reflects insight into the impact of the trauma on relationships, which is a step toward positive outcomes.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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