A nurse is planning care for a client who has ischemic stroke and is at risk for cerebral edema. Which of the following interventions should the nurse include in the plan?
Elevate the head of the bed to 30 degrees.
Administer mannitol as prescribed.
Monitor the client's intracranial pressure.
All of the above.
The Correct Answer is D
Choice A reason:
This is correct because elevating the head of the bed to 30 degrees can help reduce intracranial pressure by facilitating venous drainage and decreasing cerebral blood volume.
Choice B reason:
This is correct because administering mannitol as prescribed can help reduce intracranial pressure by creating an osmotic gradient that draws fluid out of the brain tissue and into the bloodstream.
Choice C reason:
This is correct because monitoring the client's intracranial pressure can help detect any signs of increased intracranial pressure or cerebral herniation, which can be life-threatening complications of cerebral edema.
Choice D reason:
This is correct because all of the above interventions are appropriate for a client who has ischemic stroke and is at risk for cerebral edema.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
This is incorrect because biceps brachii is innervated by C5-C6 nerve roots, which are not affected by a herniated disc at C6-C7 level.
Choice B reason:
This is the correct answer because triceps brachii is innervated by C6-C8 nerve roots, which are affected by a herniated disc at C6-C7 level.
Choice C reason:
This is incorrect because deltoid is innervated by C5-C6 nerve roots, which are not affected by a herniated disc at C6-C7 level.
Choice D reason:
This is incorrect because trapezius is innervated by cranial nerve XI (spinal accessory nerve), which is not affected by a herniated disc at C6-C7 level.
Correct Answer is D
Explanation
Choice A reason:
This is correct because elevating the head of the bed to 30 degrees can help reduce intracranial pressure by facilitating venous drainage and decreasing cerebral blood volume.
Choice B reason:
This is correct because administering mannitol as prescribed can help reduce intracranial pressure by creating an osmotic gradient that draws fluid out of the brain tissue and into the bloodstream.
Choice C reason:
This is correct because monitoring the client's intracranial pressure can help detect any signs of increased intracranial pressure or cerebral herniation, which can be life-threatening complications of cerebral edema.
Choice D reason:
This is correct because all of the above interventions are appropriate for a client who has ischemic stroke and is at risk for cerebral edema.
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