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 D

Explanation

Reasoning:

Choice A reason: Diabetes insipidus causes hypernatremia due to excessive water loss from ADH deficiency, leading to polyuria and dehydration. This increases serum sodium concentration, not dilutional hyponatremia, which is characterized by low sodium due to water retention, making DI incorrect for this condition.

Choice B reason: Hypothyroidism affects metabolism through low thyroid hormone levels, causing symptoms like fatigue and weight gain. It does not directly cause dilutional hyponatremia, as it does not involve ADH or water retention. Sodium imbalances in hypothyroidism are rare and not dilutional in nature.

Choice C reason: Hyperthyroidism increases metabolism but does not typically cause dilutional hyponatremia. It may lead to dehydration from increased metabolic demand, but this does not involve excessive water retention or ADH dysfunction, which are necessary for dilutional hyponatremia to occur.

Choice D reason: SIADH causes dilutional hyponatremia due to excessive ADH, leading to water retention in the kidneys. This dilutes serum sodium, lowering its concentration. The increased fluid volume without corresponding sodium retention is the hallmark of SIADH, making it the correct endocrine disorder.

A. Stay on oxygen therapy 24/7 B. Avoid any type of sports C. Avoid any activity that makes you short of breath D. Drink at least 8 glasses of water every day

Correct Answer is D

Explanation

Reasoning:

Choice A reason: Continuous oxygen therapy is not a standard preventive measure for sickle cell crises. Oxygen is used during acute crises to treat hypoxia from vaso-occlusion, but daily hydration is more effective for prevention, as it reduces blood viscosity and sickling, making this inappropriate.

Choice B reason: Avoiding all sports is overly restrictive for sickle cell anemia. Moderate exercise can be safe with proper hydration and rest. Complete avoidance does not directly prevent crises and may reduce quality of life, whereas hydration directly addresses the risk of sickling and vaso-occlusion.

Choice C reason: Avoiding activities causing shortness of breath is partially correct, as overexertion can trigger hypoxia and crises. However, it is less specific than hydration, which directly reduces blood viscosity and sickling, preventing crises more effectively across various situations, not just during exertion.

Choice D reason: Drinking at least 8 glasses of water daily is critical in sickle cell anemia to prevent crises. Adequate hydration reduces blood viscosity, preventing red blood cell sickling and vaso-occlusion. Dehydration increases sickling risk, making consistent fluid intake a key preventive strategy for this client.

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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

Which endocrine disorder causes the client to have dilutional hyponatremia?

Correct Answer is D

Explanation

The nurse is caring for a 13-year-old diagnosed with sickle cell anemia. The client asks the nurse what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client?

Correct Answer is D

Explanation

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A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. What blood component results in sickle cell anemia?

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The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned that the co-worker may have?