The nurse is caring for a patient recovering from an ischemic stroke.
What intervention best addresses a potential complication after an ischemic stroke?

Keep a urinary catheter in place for the entire duration of recovery.

Provide three larger meals rather than frequent small meals.

Limit the intake of insoluble fiber.

Teach the patient to perform deep breathing and coughing exercises.

Answer and Explanation

The Correct Answer is D

Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.

Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.

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Correct Answer is A

Explanation

Choice A rationale
Status epilepticus is a medical emergency characterized by continuous or rapid-fire seizures. Intravenous diazepam is one of the first-line treatments for this condition. It works by enhancing the effect of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits brain activity, thereby helping to stop the seizure.
Choice B rationale
Oral lorazepam is not typically used to halt a seizure immediately due to its slower onset of action compared to intravenous administration.
Choice C rationale
Oral phenytoin is not typically used to halt a seizure immediately. It is more commonly used for the long-term management of seizures.
Choice D rationale
Intravenous phenobarbital is a second-line treatment for status epilepticus, used when first- line treatments such as diazepam are ineffective.

A. Administering hydromorphone as needed B. Distracting the patient with activity C. Dimming the lights and reducing stimulation D. Initiating a patient-controlled analgesia (PCA) of morphine sulfate .

Correct Answer is C

Explanation

Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale

While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.

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The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately?

Correct Answer is A

Explanation

A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Correct Answer is C

Explanation

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The nurse is caring for a patient recovering from an ischemic stroke.
What intervention best addresses a potential complication after an ischemic stroke?