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 C
Explanation
Choice A rationale:
Developing influenza after receiving the vaccine the previous year is not a contraindication for receiving the vaccine this year. In fact, the vaccine is recommended annually.
Choice B rationale:
Hypertension is not a contraindication for receiving the influenza vaccine.
Choice C rationale:
Clients with a history of Guillain-Barré syndrome should generally avoid receiving the influenza vaccine due to a potential increased risk of recurrence of the syndrome.
Choice D rationale:
Allergies to dairy products are not a contraindication for receiving the influenza vaccine.
Correct Answer is A
Explanation
Choice A rationale:
Sertraline is an antidepressant medication known as a selective serotonin reuptake inhibitor (SSRI). One of the potential side effects of SSRIs is sexual dysfunction, including erectile dysfunction.
Choice B rationale:
Vancomycin is an antibiotic and is not typically associated with erectile dysfunction.
Choice C rationale:
Topiramate is an anticonvulsant medication and is not typically associated with erectile dysfunction.
Choice D rationale:
Polyethylene glycol is a laxative and is not typically associated with erectile dysfunction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.