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
Explanation
Choice A rationale:
Inflammatory bowel disease, including Crohn's disease, can lead to decreased albumin levels due to malabsorption and inflammation.
Choice B rationale:
Increased erythrocyte sedimentation rate (ESR) is more likely in inflammatory conditions.
Choice C rationale:
Decreased hematocrit is more common due to potential blood loss.
Choice D rationale:
Decreased protein levels are expected due to inflammation and malabsorption.
Correct Answer is D
Explanation
Choice A rationale:
Increasing fiber intake is a key recommendation for managing diverticulosis.
Choice B rationale:
Cellulose-containing foods, such as whole grains and vegetables, are important sources of dietary fiber and are encouraged for managing diverticulosis.
Choice C rationale:
Stimulating laxatives are not recommended for managing diverticulosis and could potentially exacerbate symptoms.
Choice D rationale:
Limiting fat intake to 30% or less is a dietary recommendation for managing diverticulosis. A high-fiber diet is also important to prevent diverticular inflammation.
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