A nurse is discussing the benefits of early ambulation after surgery with a preoperative client. Which of the following statements would be incorrect?

Early ambulation can help keep your lungs expanded and prevent pneumonia

Early ambulation is one part of preventing blood clots from forming in your legs

Early ambulation usually delays wound healing and increases the risk wound infection

Early ambulation can help your bladder and bowels recover from the anaesthesia

Answer and Explanation

The Correct Answer is C

A. "Early ambulation can help keep your lungs expanded and prevent pneumonia":
This statement is correct. Early ambulation is beneficial for respiratory function as it helps to keep the lungs expanded, encouraging deeper breaths and better oxygenation. This can help prevent complications like pneumonia and atelectasis, which are common after surgery due to immobility and anesthesia.

B. "Early ambulation is one part of preventing blood clots from forming in your legs":
This statement is also correct. Early ambulation is an important measure in preventing deep vein thrombosis (DVT) and pulmonary embolism (PE), which are common postoperative complications. Movement and walking promote circulation, reducing the risk of blood clots forming in the legs.

C. "Early ambulation usually delays wound healing and increases the risk of wound infection":
This statement is incorrect. Early ambulation does not delay wound healing or increase the risk of infection. In fact, early movement can help improve circulation, which is crucial for wound healing and tissue repair. Gentle movement and ambulation typically have positive effects on wound healing by promoting blood flow to the surgical site. However, patients should avoid excessive strain or stress on the wound to prevent dehiscence or other complications.

D. "Early ambulation can help your bladder and bowels recover from the anesthesia":
This statement is correct. Early ambulation helps stimulate gastrointestinal and urinary systems, which may be sluggish after anesthesia. Walking can encourage the return of normal bowel and bladder function by promoting peristalsis and helping to prevent constipation or urinary retention, both of which can be common after surgery.

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Correct Answer is B

Explanation

A. Cardiac dysrhythmias:
While cardiac dysrhythmias can occur after a stroke, especially in the acute phase due to changes in autonomic regulation and increased sympathetic tone, they are not a direct compensatory response to increase cerebral blood flow. Dysrhythmias, such as atrial fibrillation, can occur as a result of stroke but are not a physiological response to attempts by the body to increase cerebral perfusion.

B. Hypertension:
Hypertension is a common cardiovascular response in the acute phase of a stroke. The body increases blood pressure to enhance cerebral perfusion and ensure that oxygen and nutrients are delivered to the brain, especially if there is impaired blood flow due to a clot or hemorrhage. This compensatory mechanism helps maintain adequate cerebral blood flow to areas at risk of ischemia. Therefore, hypertension is the most likely cardiovascular sign that the nurse would observe in response to a stroke, and it is a key sign that needs to be closely monitored and managed.

C. 53 and 54 heart sounds:
The presence of 53 and 54 heart sounds, also known as extra heart sounds, such as S3 and S4, may indicate heart failure, volume overload, or diastolic dysfunction. While these sounds can be associated with certain cardiovascular conditions, they are not a typical sign observed in the acute phase of a stroke as the body attempts to increase cerebral blood flow. These heart sounds are more related to heart conditions rather than stroke-induced changes in cerebral perfusion.

D. Fluid overload:
Fluid overload, although a potential complication in stroke patients (especially if they are given excessive IV fluids or have renal issues), is not a primary compensatory mechanism for increasing cerebral blood flow. Fluid overload could exacerbate other conditions, like increased intracranial pressure or pulmonary edema, but it does not directly serve the purpose of improving cerebral perfusion during a stroke. Hypertension, on the other hand, is a direct response to try to maintain cerebral blood flow.

A. Recent thoracic surgery within the past week B. Uncontrolled hypertensive crisis C. Age over 65 years D. Head trauma with active cerebral hemorrhage

Correct Answer is C

Explanation

A. Recent thoracic surgery within the past week:
Recent surgery, especially in the thoracic region, is a contraindication for the use of tissue plasminogen activator (tPA) in stroke treatment. tPA is a thrombolytic agent that dissolves clots, but it also increases the risk of bleeding, including in areas where surgery has recently occurred. Using tPA in this situation can potentially lead to life-threatening bleeding complications.

B. Uncontrolled hypertensive crisis:
Uncontrolled hypertension is a contraindication for tPA. High blood pressure can increase the risk of hemorrhagic transformation (bleeding into the brain) when using thrombolytic therapy like tPA. A hypertensive crisis (typically systolic BP > 185 mmHg or diastolic BP > 110 mmHg) must be managed and brought under control before administering tPA to minimize the risk of bleeding complications.

C. Age over 65 years:
While age over 65 years may increase the risk of complications from tPA, it is not an absolute contraindication for its use. Guidelines for tPA administration in stroke patients typically focus more on factors like time from symptom onset (usually within 4.5 hours), the presence of contraindications like recent surgery or uncontrolled hypertension, and the overall clinical condition. Age itself is not a reason to withhold tPA unless other risk factors are present.

D. Head trauma with active cerebral hemorrhage:
Head trauma with active cerebral hemorrhage is a definitive contraindication for tPA. Since tPA is a clot-busting drug, it can worsen bleeding in the brain, especially in cases where there is ongoing hemorrhage from trauma. This significantly increases the risk of severe neurological damage and even death, so tPA should not be administered in such situations.

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A nurse is discussing the benefits of early ambulation after surgery with a preoperative client. Which of the following statements would be incorrect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow?

Correct Answer is B

Explanation

Which of the following is not a contraindication for the use of tissue plasminogen activator (PA) in the treatment of stroke?

Correct Answer is C

Explanation

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