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?

Cardiac dysrhythmias

Hypertension

53 and 54 heart sounds

Fluid overload

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

A. 2-6 hours before meals:
This timeframe is too long for rapid-acting insulin like Lispro. Rapid-acting insulins, such as Lispro, begin to work quickly after administration, typically within 15 minutes, and peak around 1 to 2 hours after injection. Administering it 2-6 hours before meals would not align with the timing of food intake and would likely lead to hypoglycemia before the meal. Timing of rapid-acting insulin should be closer to the meal to match the rise in blood glucose levels that occurs after eating.

B. Lispro lasts 24 hours and does not have to be timed with meals:
This statement is incorrect. Lispro is a rapid-acting insulin, and its duration of action is much shorter than 24 hours, typically lasting about 3-5 hours. It is crucial to time the administration of Lispro with meals to match its peak action with the rise in blood glucose levels after eating. A long-acting insulin would be the type that lasts for 24 hours, but that is not the case with Lispro.

C. 15-30 minutes before meals:
Lispro is a rapid-acting insulin, and its onset of action occurs within 15 minutes after injection. It is most effective when administered within 15-30 minutes before the start of a meal, as it peaks in about 1-2 hours and works to regulate blood glucose levels during and after the meal. This timing ensures that insulin works in concert with the rise in blood glucose following food intake, helping prevent hyperglycemia.

D. 60 minutes before meals:
Administering Lispro 60 minutes before a meal is too early. Rapid-acting insulins, such as Lispro, begin working quickly and reach peak action within 1-2 hours. If administered too far in advance, there is a risk that the insulin may have peaked before the meal, leading to a potential drop in blood glucose levels before the meal is consumed. This could result in hypoglycemia. Therefore, administering it closer to the meal, within 15-30 minutes, is the optimal timing.

Correct Answer is ["2"]

Explanation

Given:

Desired dose: Dextromethorphan 30 mg PO

Available concentration: Dextromethorphan oral liquid 75 mg/5 mL

To find:

Volume to administer (in mL)

Step 1: Set up the proportion

We can use the following proportion to solve the problem:

(Desired dose) / (Available concentration) = Volume to administer

Step 2: Substitute the values

Plugging in the given values, we get:

(30 mg) / (75 mg/5 mL) = Volume to administer

Step 3: Simplify

To simplify, we can invert the denominator and multiply:

(30 mg) x (5 mL / 75 mg) = Volume to administer

The "mg" units cancel out, leaving us with:

(30 x 5 mL) / 75 = Volume to administer

Step 4: Calculate

Performing the multiplication and division, we get:

150 mL / 75 = Volume to administer

2mL = Volume to administer

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with type 1 diabetes mellitus. When planning administration for rapid-acting insulin Lispro, the nurse knows to administer it during which timeframe based on the onset of action?

Correct Answer is B

Explanation

A nurse is preparing to administer dextromethorphan 30 mg PO. The amount available is dextromethorphan oral liquid 7.5 mg/5mL. How many should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

Correct Answer is ["2"]

Explanation

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