The client is diagnosed with a transient ischemic attack (TI

My heart rate will no longer be irregular.

This medication will help lower my blood pressure.

I will have decreased pain to my legs when I walk.

Clopidogrel will prevent clots from forming.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Clopidogrel is an antiplatelet agent that prevents platelet aggregation but does not affect arrhythmias. It reduces clot formation risk, which is critical for patients with a history of TIA or stroke.

Choice B rationale

Clopidogrel does not lower blood pressure. It works by inhibiting platelet aggregation to prevent thrombus formation, not addressing the mechanisms of hypertension or blood pressure control.

Choice C rationale

Clopidogrel does not directly affect peripheral artery disease symptoms, such as leg pain. It is used to reduce the risk of thrombotic events like strokes and heart attacks by preventing platelet aggregation.

Choice D rationale

Clopidogrel inhibits platelet aggregation by blocking the ADP receptor on platelets, reducing the risk of clot formation. This is crucial for preventing ischemic events in patients with a history of TIA.

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Correct Answer is A

Explanation

Choice A rationale

Extremely high systolic BP (220 mmHg), bradycardia (HR 30), and altered respirations (RR 6) suggest Cushing's triad, a hallmark of increased ICP due to severe brain injury.

Choice B rationale

Hypothermia (T92.5°F) and hypotension (BP 90/64) do not indicate increased ICP but may result from shock or hypothermic conditions affecting autonomic responses.

Choice C rationale

Hyperthermia (T103.1°F) and tachycardia (HR 132) are commonly seen in infection or hypermetabolic states, not directly pointing to raised ICP.

Choice D rationale

Mild hypertension (BP 200/94) with normal HR (90) and RR (18) does not fit the classic signs of increased ICP like Cushing's triad.

A. Elevate the head of the bed 30-45 degrees. B. Perform serial neurologic assessments while hospitalized. C. Suction frequently to prevent development of pneumonia. D. Administer sedatives/pain medications per orders. E. Stimulate the patient with TV, music, lights, and family at bedside.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Elevating the head 30-45 degrees aids in venous drainage and reduces intracranial pressure. It also prevents cerebral edema by improving cerebrospinal fluid outflow without compromising cerebral perfusion.

Choice B rationale

Serial neurological assessments help monitor for changes in intracranial pressure, enabling early intervention. They ensure timely recognition of symptoms indicating worsening pressure or neurological deterioration.

Choice C rationale

Frequent suctioning increases intracranial pressure due to stimulation of the vagus nerve, leading to coughing or gagging. It can also induce hypoxia, further exacerbating intracranial pressure.

Choice D rationale

Administering sedatives and pain medications reduces cerebral metabolic rate and sympathetic stimulation, which in turn prevents spikes in intracranial pressure. It also helps prevent agitation and discomfort in the patient.

Choice E rationale

Stimulating the patient with TV, music, lights, and family increases sensory input, which can elevate intracranial pressure. Overstimulation can cause agitation, raising intracranial pressure further.

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The client is diagnosed with a transient ischemic attack (TI

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with an acute brain injury.Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Correct Answer is A

Explanation

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a patient with an acute head injury.Which actions should the nurse take to achieve this goal? (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

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