Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention?

Initiating early mobilization

Maximizing partial pressure of carbon dioxide (PaCO2)

Positioning the client to avoid intracranial pressure (ICP)

Administering hypertonic intravenous (IV) solution

Answer and Explanation

The Correct Answer is A

Reasoning:

Choice A reason: Early mobilization post-ischemic stroke is critical during recovery to prevent complications like deep vein thrombosis, pneumonia, and muscle atrophy. It promotes neuroplasticity, improves circulation, and enhances functional recovery, making it a priority intervention in the immediate recovery period to optimize outcomes and reduce disability.

Choice B reason: Maximizing PaCO2 is not appropriate post-ischemic stroke. Elevated CO2 causes cerebral vasodilation, potentially increasing ICP, which is harmful. Maintaining normal CO2 levels supports cerebral perfusion without exacerbating edema, making this intervention irrelevant or potentially dangerous in stroke recovery.

Choice C reason: Positioning to avoid ICP is more relevant for hemorrhagic stroke, where ICP is a concern. In ischemic stroke, ICP is less likely unless severe edema occurs. Early mobilization takes precedence to prevent complications and promote recovery, making ICP positioning a secondary concern.

Choice D reason: Administering hypertonic IV solutions is used in cases of cerebral edema or elevated ICP, more common in hemorrhagic stroke. In ischemic stroke, hydration with isotonic fluids supports perfusion, but early mobilization is the priority to enhance recovery and prevent immobility-related complications.

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Correct Answer is C

Explanation

Reasoning:

Choice A reason: A chest radiograph evaluates lung or cardiac issues but is not the first test for symptoms of tiredness, coldness, and shortness of breath with tachycardia. These suggest anemia, and a CBC directly assesses hemoglobin and red blood cell counts, making it more relevant than imaging for initial evaluation.

Choice B reason: An ECG assesses cardiac rhythm and ischemia, useful for tachycardia, but it does not address the underlying cause of fatigue, coldness, and dyspnea. These symptoms suggest anemia, and a CBC is needed to confirm low hemoglobin before evaluating cardiac function with an ECG.

Choice C reason: A complete blood count (CBC) is the most appropriate test, as tiredness, coldness, shortness of breath, and tachycardia suggest anemia. A CBC measures hemoglobin, hematocrit, and red blood cell indices, identifying anemia’s presence and type, guiding further diagnostic and therapeutic interventions for the client’s symptoms.

Choice D reason: Antibiotics treat infections, but tiredness, coldness, dyspnea, and tachycardia point to anemia, not infection. Without fever or infection signs, antibiotics are inappropriate. A CBC is needed to confirm anemia as the cause, making it the priority over empirical antibiotic therapy.

A. A client admitted with suspected cocaine overdose B. A client admitted with sepsis C. A client with heart failure and renal failure D. A client with a stage IV pressure injury

Correct Answer is B

Explanation

Reasoning:

Choice A reason: A cocaine overdose can cause cardiovascular complications like hypertension or infarction, but it is not a primary trigger for DIC. While cocaine may induce inflammation or vascular damage, it lacks the systemic activation of coagulation pathways seen in conditions like sepsis, making it a less likely cause of DIC in this context.

Choice B reason: Sepsis is a leading cause of DIC due to systemic infection triggering widespread activation of the coagulation cascade. Endotoxins or cytokines promote microthrombi formation, consuming platelets and clotting factors, leading to bleeding tendencies. Sepsis-induced inflammation and endothelial damage make this client the most at risk for developing DIC.

Choice C reason: Heart failure and renal failure may cause fluid imbalances and inflammation but are not primary triggers for DIC. These conditions can contribute to coagulopathy indirectly, but they lack the intense systemic inflammatory response and endothelial injury seen in sepsis, making them less likely to cause DIC.

Choice D reason: A stage IV pressure injury may lead to localized infection or inflammation, but it is not a primary driver of DIC. While severe infections could contribute, the systemic activation of coagulation seen in DIC is more commonly triggered by conditions like sepsis, making this client less at risk.

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Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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