The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient's plan of care? (Select all that apply!
Make frequent neurological assessments
Maintain MAP less than 150 mm Hg
Restrain affected limb to prevent injury
Prepare for thrombolytic administration
Maintain CO2 level at 50mmHg
Correct Answer : A,D
A. Make frequent neurological assessments: Ongoing neurological assessments allow early detection of changes in level of consciousness, motor strength, speech, or pupil response. These findings help evaluate stroke progression and response to interventions. Frequent monitoring supports timely escalation of care if deterioration occurs.
B. Maintain MAP less than 150 mm Hg: Blood pressure management in acute ischemic stroke is guided by specific parameters, especially if thrombolytics are considered. Excessive lowering of blood pressure can reduce cerebral perfusion to ischemic tissue. A strict MAP less than 150 mm Hg is not a standard priority goal in this context.
C. Restrain affected limb to prevent injury: Restraining a limb can increase agitation, reduce mobility, and raise the risk of injury or skin breakdown. Supportive positioning and safety measures are preferred over restraints. Therapeutic handling promotes circulation and recovery.
D. Prepare for thrombolytic administration: With intracranial hemorrhage ruled out, preparation for thrombolytic therapy becomes a priority if the patient meets eligibility criteria. Timely administration improves cerebral perfusion and neurological outcomes. Nursing actions include IV access, labs, and close monitoring.
E. Maintain CO₂ level at 50 mm Hg: Elevated carbon dioxide levels cause cerebral vasodilation, which can increase intracranial pressure. Stroke care focuses on maintaining normal oxygenation and ventilation. Hypercapnia is not a therapeutic goal in acute stroke management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Glucose value of 125 mg/dL: A glucose level of 125 mg/dL is slightly elevated and may reflect impaired fasting glucose or stress-related hyperglycemia. While it warrants monitoring, it does not specifically indicate poor nutritional status requiring immediate re-evaluation of a nutritional care plan.
B. Albumin value of 2.0 g/dL: Albumin levels below normal suggest poor protein status, malnutrition, or chronic illness. A value of 2.0 g/dL is significantly low and associated with impaired wound healing, edema, and increased risk of infection. This finding signals the need to reassess nutritional intake and support.
C. Potassium value of 4.0 mEq/L: A potassium level of 4.0 mEq/L falls within the normal reference range. It indicates adequate electrolyte balance and does not suggest a nutritional deficiency or need for care plan modification.
D. Pre-albumin 28 mg/dL: Pre-albumin within this range reflects adequate short-term protein status and recent nutritional intake. It is often used to monitor nutritional improvement and does not indicate a need for re-evaluation when within normal limits.
Correct Answer is D
Explanation
A. IV Dextrose 10% bolus: Administering dextrose can increase serum osmolality and potentially worsen cerebral edema. It is not indicated for reducing intracranial pressure. Dextrose is typically reserved for treating hypoglycemia.
B. Heparin infusion: Anticoagulation is not a primary intervention for elevated intracranial pressure. Heparin would be contraindicated in patients at risk of intracranial bleeding or cerebral edema.
C. Furosemide PO: Oral furosemide has a delayed onset and limited effectiveness in rapidly reducing intracranial pressure. While loop diuretics may be used adjunctively, IV administration is preferred for acute management.
D. IV Mannitol or hypertonic saline: Osmotic agents such as IV mannitol or hypertonic saline are first-line therapies for elevated ICP. They create an osmotic gradient that draws fluid from cerebral tissue into the intravascular space, reducing cerebral edema and pressure effectively and rapidly.
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