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 B

Explanation

Reasoning:

Choice A reason: A 13-year-old female post-menarche may develop iron deficiency anemia due to menstrual blood loss, but this is less common unless heavy bleeding occurs. Adolescents generally have good iron stores unless dietary intake is poor, making anemia less likely compared to older adults with chronic conditions.

Choice B reason: An 81-year-old female with chronic heart failure is most likely to have anemia due to chronic disease, common in the elderly. Heart failure causes reduced tissue perfusion, inflammation, and possible renal impairment, all contributing to decreased erythropoiesis and anemia, making this the highest-risk profile.

Choice C reason: A 48-year-old male with a high-stress job may have mild anemia if stress affects diet or causes gastrointestinal bleeding, but this is less common. Without specific risk factors like blood loss or nutritional deficiency, his anemia risk is lower than that of an elderly patient with chronic illness.

Choice D reason: A 50-year-old female in menopause is less likely to have anemia, as cessation of menstruation reduces iron loss. While perimenopause may cause irregular bleeding, postmenopausal women typically have lower anemia risk unless other factors, like nutritional deficiencies or chronic diseases, are present.

A. I sense that you are happy it was not a stroke B. TIA symptoms are short-lived and resolve within 24 hours C. People who experience a TIA will develop a stroke D. TIA is a warning sign. Let’s talk about lowering your risks

Correct Answer is D

Explanation

Reasoning:

Choice A reason: Acknowledging the client’s relief does not educate them about the TIA’s significance. TIAs indicate transient cerebral ischemia, increasing stroke risk, but this response fails to address the need for risk modification, missing an opportunity to promote preventive measures critical for stroke prevention.

Choice B reason: Stating that TIA symptoms resolve within 24 hours is factually correct but does not emphasize the serious nature of TIAs as stroke precursors. Without addressing risk reduction, this response fails to educate the client on the need for lifestyle changes or medical intervention to prevent future events.

Choice C reason: Saying all TIA patients will develop a stroke is inaccurate, as not all progress to stroke. TIAs significantly increase stroke risk, but many can be prevented with proper management. This response is overly fatalistic and does not encourage proactive risk reduction strategies.

Choice D reason: Explaining that a TIA is a warning sign and discussing risk reduction educates the client about its significance as a transient cerebral ischemia event, increasing stroke risk. This response promotes lifestyle changes, medication adherence, and medical follow-up, empowering the client to prevent future strokes effectively.

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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

A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which individual is most likely to have anemia?

Correct Answer is B

Explanation

A client who has experienced an initial transient ischemic attack (TIA) states: “I’m glad it wasn’t anything serious.” Which is the best nursing response to this statement?

Correct Answer is D

Explanation

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client’s diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client’s diet allows for easy swallowing?

A client with a new diagnosis of ischemic stroke was treated in the ED with tissue plasminogen activator (t-PA) and then admitted to the ICU. In addition to closely monitoring the client’s cardiac and neurologic status, the nurse monitors the client for signs of what complication?

The nurse assesses a client who has been diagnosed with Addison's disease. Which of the following is a diagnostic sign of this disease?

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The nurse is caring for a client with an exacerbation of sickle cell disease (SCD). Which finding indicates to the nurse that the client is experiencing a liver complication from this condition?

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