Which of the following is a priority nursing intervention for a client admitted with an ischemic stroke?

Position the client in semi-Fowler’s for optimal respiratory function

Put the client in mild Trendelenburg position to decrease hypertension

Place the client flat for 24 hours to decrease cerebral ischemia

Raise the head of the bed 30 degrees for cerebral perfusion

Answer and Explanation

The Correct Answer is D

Choice A reason: Semi-Fowler’s aids breathing but doesn’t optimize cerebral blood flow, critical in ischemic stroke to perfuse brain tissue, less urgent than perfusion.

Choice B reason: Trendelenburg lowers the head, risking increased intracranial pressure in stroke, not reducing hypertension effectively, contraindicated for cerebral ischemia.

Choice C reason: Flat positioning may increase intracranial pressure, worsening ischemia; elevation enhances perfusion, so keeping flat isn’t the priority intervention.

Choice D reason: Raising the head 30 degrees improves cerebral perfusion by balancing blood flow and reducing pressure, the priority to minimize ischemic damage.

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Correct Answer is D

Explanation

Choice A reason: Maintaining oxygen saturation helps symptoms but doesn’t diagnose the cause (e.g., MI), delaying critical evaluation of atypical pain and dyspnea.

Choice B reason: Ibuprofen relieves pain but risks bleeding in potential MI, not addressing cardiac etiology of jaw, back pain, and shortness of breath urgently.

Choice C reason: Acetaminophen eases pain but doesn’t assess or treat potential cardiac ischemia, missing the diagnostic priority for these MI-like symptoms.

Choice D reason: An EKG identifies cardiac ischemia (e.g., MI) in atypical pain (jaw, back), dyspnea, and nausea, guiding urgent treatment, the priority action here.

A. Rest with the legs above heart level B. Adjust the thermostat so that the environment is warm C. Apply a heating pad on a low setting to help relieve leg pain D. Wear antiembolic stockings during the day

Correct Answer is B

Explanation

Choice A reason: Elevating legs above heart level aids venous return, not arterial flow, worsening PAD’s poor circulation, reducing oxygen to ischemic tissues further.

Choice B reason: Warm environments dilate peripheral vessels, improving blood flow to PAD-affected limbs, reducing claudication pain and supporting tissue perfusion safely.

Choice C reason: Heating pads risk burns in PAD due to reduced sensation and poor healing, potentially worsening ischemic damage rather than relieving pain effectively.

Choice D reason: Antiembolic stockings prevent clots in venous stasis, not PAD, an arterial issue, and may compress arteries, further impairing circulation to legs.

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Which of the following is a priority nursing intervention for a client admitted with an ischemic stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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