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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This is the correct answer because peripheral neuropathy affects the sensory nerves, which can cause loss of sensation, especially in the distal parts of the body. Diabetes mellitus is a common cause of peripheral neuropathy.
Choice B reason:
This is incorrect because peripheral neuropathy does not affect the motor nerves, which control muscle tone and reflexes. Increased muscle tone and reflexes in the upper limbs are more likely to indicate a central nervous system disorder, such as a stroke or spinal cord injury.
Choice C reason:
This is incorrect because peripheral neuropathy can cause decreased pain perception in any part of the body, not just the hands and fingers. However, this is not a specific finding for peripheral neuropathy, as other conditions can also impair pain perception, such as spinal cord injury or opioid use.
Choice D reason:
This is incorrect because peripheral neuropathy does not affect the autonomic nerves, which control sweating and flushing. Increased sweating and flushing in the face and neck are more likely to indicate a sympathetic nervous system disorder, such as pheochromocytoma or carcinoid syndrome.
Correct Answer is A
Explanation
Choice A reason:
This is a correct answer, as the medication increases dopamine levels in the brain, which helps to improve the symptoms of Parkinson's disease, such as tremors, rigidity, and bradykinesia.
Choice B reason:
This is an incorrect answer, as the medication does not decrease acetylcholine levels in the brain, but rather increases dopamine levels. Acetylcholine is another neurotransmitter that controls muscle contraction, learning, and memory.
Choice C reason:
This is an incorrect answer, as the medication does not increase serotonin levels in the brain, but rather increases dopamine levels. Serotonin is another neurotransmitter that controls mood, sleep, and appetite.
Choice D reason:
This is an incorrect answer, as the medication does not decrease glutamate levels in the brain, but rather increases dopamine levels. Glutamate is another neurotransmitter that controls excitatory signals in the brain.
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