Which intervention would the nurse implement to provide relief of the patient's discomfort when presenting to the clinic with a red, swollen, circumscribed, acutely, tender area near the eye and in the lid margin?

Application of a warm, moist compress 4 times a day

Administration of non-steroidal anti-inflammatory eyedrops

Wash eye before sleep time

Administration of artificial tear

Answer and Explanation

The Correct Answer is A

A.   A warm, moist compress helps alleviate discomfort associated with a stye or hordeolum.
B.   NSAID eye drops may not be appropriate for treating local swelling or infection.
C.   Washing the eye can help with hygiene but is not the primary intervention for a stye.
D.   Artificial tears can provide relief for dry eyes but do not address the infection or swelling caused by a stye.

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

Explanation

A. Managing sedation helps prevent agitation and decreases metabolic demands, which can exacerbate ICP.
B. Monitoring volume status is essential to prevent fluid imbalances that can worsen ICP.
C. Completing hourly endotracheal suctioning is not appropriate for this patient. Excessive suctioning can cause increased ICP and should be done cautiously.
D. Ensuring proper ventriculostomy transducer levels is critical for accurate measurement of ICP.
E. Elevating the head of the bed 30° helps improve venous drainage and reduces ICP.

A. The BP must be lower than 130/70 mm Hg to receive fibrinolytic agents. B. Elevated BPs are expected after a stroke, and drug therapy should be initiated. C. A lower BP is a protective response to maintain cerebral perfusion. D. Drugs to lower BP are recommended if the BP is 220/120 mm Hg or higher

Correct Answer is D

Explanation

A. The BP must be lower than 180/105 mm Hg to receive fibrinolytic agents, not 130/70 mm Hg.
B. Elevated BPs are common immediately after a stroke, but drug therapy to lower BP is not initiated unless it reaches high levels (typically > 220/120 mm Hg).
C. A lower BP does not act as a protective response; maintaining a higher BP can be necessary initially after a stroke to ensure adequate cerebral perfusion.

D. If BP is 220/120 mm Hg or higher after ischemic stroke, aggressive antihypertensive therapy is initiated to reduce the risk of hemorrhagic transformation and other complications.

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Which intervention would the nurse implement to provide relief of the patient's discomfort when presenting to the clinic with a red, swollen, circumscribed, acutely, tender area near the eye and in the lid margin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care? (Select All that Apply.)

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

Explanation

Which statement is accurate about the recommendations for BP management after an ischemic stroke?

Correct Answer is D

Explanation

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Which method of measurement is the gold standard for obtaining intracranial pressures?

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?