A nurse is caring for a newly admitted client with an aortic dissection. The nurse proceeds to implement new orders, which of the following is appropriate for this client?

Opioid therapy

Promote a quiet environment by clustering care

Encourage heavy weight lifting for physical activity

Answer and Explanation

The Correct Answer is B

Choice A reason: Opioid therapy may be used for pain in aortic dissection but is not the most appropriate primary intervention. Controlling blood pressure and heart rate to prevent dissection progression is critical, and a quiet environment supports this by reducing stress and sympathetic activation, which could elevate pressure.

Choice B reason: Promoting a quiet environment by clustering care is appropriate for aortic dissection. Minimizing stress and activity reduces blood pressure and heart rate, preventing further tearing of the aortic wall. Clustering care limits disturbances, stabilizing hemodynamics and supporting medical management to prevent dissection progression.

Choice C reason: Encouraging heavy weight lifting is contraindicated in aortic dissection, as it increases blood pressure and shear stress on the aortic wall, risking further dissection or rupture. Physical activity must be restricted, and a calm environment is prioritized to maintain hemodynamic stability and prevent catastrophic complications.

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Correct Answer is C

Explanation

Choice A reason: Thrombolytic administration within 10 hours is incorrect, as the therapeutic window for thrombolytics like alteplase in ischemic stroke is typically 3–4.5 hours from symptom onset. Beyond this, the risk of hemorrhage outweighs benefits, making timely administration critical to restore cerebral blood flow and minimize brain damage.

Choice B reason: Completing neurologic assessments every 12 hours is important for monitoring but is not the next action post-CT confirming ischemic stroke. Urgent thrombolytic therapy (e.g., alteplase) within 4.5 hours takes priority to dissolve the clot, restore perfusion, and limit infarct size, improving neurological outcomes.

Choice C reason: Alteplase administration within 4.5 hours is the next step post-CT confirming ischemic stroke. This thrombolytic dissolves the clot obstructing cerebral blood flow, minimizing brain tissue damage. The narrow time window ensures efficacy and reduces hemorrhage risk, making it the priority intervention to improve stroke outcomes.

Choice D reason: Vancomycin administration after blood culture is irrelevant for ischemic stroke, which results from a clot, not infection. Antibiotics like vancomycin treat bacterial infections, not cerebral ischemia. The priority is thrombolytic therapy like alteplase to restore blood flow and prevent further brain tissue damage.

A. Administer opioids B. Reduce stimuli C. Apply restraints D. Administer antihypertensives

Correct Answer is B

Explanation

Choice A reason: Administering opioids is not the primary intervention for a restless client waking from a coma. Opioids may sedate but can depress respiration and mask neurological changes, complicating assessment of brain injury recovery. Reducing stimuli is safer to calm agitation without compromising neurological monitoring.

Choice B reason: Reducing stimuli is critical for a client with a traumatic brain injury waking restlessly from a coma. Excessive noise, light, or activity can exacerbate agitation and increase intracranial pressure. A calm environment minimizes neurological stress, supports recovery, and prevents complications like seizures or further brain injury.

Choice C reason: Applying restraints is not ideal, as they can increase agitation and injury risk in a restless brain injury client. Restraints may elevate intracranial pressure by causing stress or struggle. Non-restrictive measures, like reducing stimuli, are preferred to manage restlessness safely and effectively.

Choice D reason: Administering antihypertensives is not indicated unless hypertension is present. Restlessness in a brain injury client is likely due to neurological irritation, not blood pressure. Reducing stimuli addresses the cause directly, while antihypertensives may lower cerebral perfusion pressure, potentially worsening brain recovery.

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A nurse is caring for a newly admitted client with an aortic dissection. The nurse proceeds to implement new orders, which of the following is appropriate for this client?

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Naxlex Comprehensive Predictor Exams

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