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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Nasogastric suction removes gastric acid (HCl), reducing hydrogen ions, raising pH, and causing metabolic alkalosis, a common post-surgical complication here.
Choice B reason: Panic attacks cause respiratory alkalosis from hyperventilation, lowering CO2, not metabolic alkalosis, which involves base excess, unrelated to this ABG.
Choice C reason: ESRD typically causes metabolic acidosis from acid retention, not alkalosis, as kidneys fail to excrete hydrogen, opposing this patient’s ABG findings.
Choice D reason: Epidural catheters manage pain with analgesics, not affecting acid-base balance or causing metabolic alkalosis, irrelevant to the ABG shift observed.
Correct Answer is B
Explanation
Choice A reason: 1 tablet (50 mcg) provides half the 100 mcg dose, insufficient for hypothyroidism treatment, underdosing the required thyroid hormone replacement level.
Choice B reason: 2 tablets (50 mcg each) equal 100 mcg, matching the prescribed dose, ensuring adequate T4 replacement for hypothyroidism’s metabolic needs daily.
Choice C reason: 3 tablets (150 mcg) exceed the 100 mcg dose, risking hyperthyroidism symptoms like tachycardia or nervousness from excessive thyroid hormone administration.
Choice D reason: 4 tablets (200 mcg) grossly overdose the 100 mcg requirement, potentially causing severe thyrotoxicosis, disrupting metabolism and cardiac function dangerously.
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