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 ["A","D","E"]

Explanation

Choice A reason: Barrel chest develops in emphysema from chronic air trapping, overexpanding lungs and flattening the diaphragm, altering thoracic shape over years.

Choice B reason: Edema relates to right heart failure from cor pulmonale, a late emphysema complication, not a direct or universal finding after five years.

Choice C reason: Productive cough is typical in chronic bronchitis, not emphysema, which features alveolar destruction and minimal mucus, leading to dry cough instead.

Choice D reason: Dyspnea in emphysema results from alveolar loss reducing oxygen exchange, forcing compensatory rapid breathing, a core symptom even after five years.

Choice E reason: Clubbed fingers occur in chronic hypoxia from emphysema, as poor oxygenation over years triggers nail bed angiogenesis, a common late finding.

A. Sun decreases the risk of developing a rash B. I can take ibuprofen for my joint pain C. Fever is an initial sign of a flare-up D. I should rest in between periods of activity

Correct Answer is A

Explanation

Choice A reason: Sun exposure triggers lupus rashes by inducing photosensitivity, increasing inflammation via UV damage, so stating it decreases risk is incorrect and needs correction.

Choice B reason: Ibuprofen, an NSAID, reduces lupus joint pain by inhibiting prostaglandin synthesis, a common and appropriate management strategy, so this is accurate.

Choice C reason: Fever signals lupus flare-ups from systemic inflammation, an early immune response marker, making this statement correct and aligned with disease patterns.

Choice D reason: Resting between activities conserves energy and reduces lupus fatigue and inflammation, a recommended self-management technique, so this is appropriate advice.

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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

The nurse is caring for a client with a diagnosis of emphysema of five years. Which of the following findings should the nurse expect to see during the morning assessment? (Select all that apply)

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

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Correct Answer is A

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