Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 70year old client diagnosed with a hemorrhagic stroke was admitted 1 day ago. His
medical history includes hypertension, osteoarthritis, and type 2 diabetes. He has right sided
paralysis, garbled speech, and a weak cough reflex. This morning he is restless. Vital signs are Blood Pressure 160/80, pulse 110, respirations 24, oxygen saturation 90% Which of the following Interventions will the nurse take to avoid complications? Select all that apply
Select All that Apply)
A. Apply oxygen
Correct. Applying oxygen can help improve the client's oxygen saturation and prevent hypoxia, which can worsen the brain injury.
B. Monitor blood pressure
Correct. Monitoring blood pressure is essential for a client with a hemorrhagic stroke, as hypertension can increase the risk of bleeding and rebleeding.
C. Implement seizure precautions
Correct. Implementing seizure precautions can protect the client from injury and aspiration in case of a seizure, which can occur due to increased intracranial pressure or irritation of the brain tissue.
D. Provide oral fluids
Incorrect. Providing oral fluids is contraindicated for a client with a weak cough reflex, as it can increase the risk of aspiration pneumonia.
E. Turn the client twice each shift
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.
A. Fracture of the skull
Fracture of the skull is not a consequence of increased ICP, but rather a possible cause of it. A fracture can allow blood or cerebrospinal fluid (CSF) to leak into the cranial cavity and increase the pressure inside the skull. This is an incorrect choice.
B. Ischemia
Ischemia is a condition where the blood supply to a tissue or organ is reduced or blocked, resulting in oxygen deprivation and tissue damage or death. Increased ICP can cause ischemia by compressing blood vessels and reducing cerebral perfusion pressure (CPP), which is the difference between mean arterial pressure (MAP) and ICP. CPP must be maintained above 60mmHg to ensure adequate blood flow to the brain. This is a correct choice.
C. Hypotension
Hypotension is a condition where the blood pressure is abnormally low, which can impair organ function and perfusion. Increased ICP can cause hypotension by stimulating the vagus nerve, which slows down the heart rate and lowers the cardiac output and MAP. This reduces the CPP and increases the risk of ischemia. This is a correct choice.
D. Hyperventilation
Hyperventilation is a condition where the breathing rate and depth are increased, resulting in lower levels of carbon dioxide (CO2) in the blood. Increased ICP can cause hyperventilation by stimulating the respiratory center in the brainstem, which tries to lower the CO2 levels and increase the pH of the blood. This causes cerebral vasoconstriction and reduces ICP temporarily, but also reduces CPP and increases the risk of ischemia. This is a correct choice.
E. Increase in Glasgow Coma Score
A nurse is providing education to a group of older adults about the risk of stroke. Which selections made by the group indicate an understanding of the teaching? Select All that Apply (Select All that Apply.)
A. Changes in face, arm movement, or speech could indicate signs of a stroke.
Changes in face, arm movement, or speech could indicate signs of a stroke. This is a correct choice. These are some of the common signs of a stroke that can be detected using the FAST acronym (Face drooping, Arm weakness, Speech difficulty, Time to call 911). Recognizing these signs and seeking immediate medical attention can improve the chances of survival and recovery from a stroke.
B. Hypotension, dehydration, and age are risk factors for stroke.
Hypotension, dehydration, and age are risk factors for stroke. This is an incorrect choice.Hypotension (low blood pressure) is not a risk factor for stroke; rather, hypertension (high blood pressure) is one of the major risk factors for stroke. Dehydration can cause hypotension, which can lead to dizziness and fainting, but not necessarily stroke. Age is a nonmodifiable risk factor for stroke, meaning that it cannot be changed or prevented. Older adults have a higher risk of stroke than younger adults, but this does not mean that younger adults are immune to stroke.
C. Everyone should take lowdose aspirin to reduce stroke risks
Everyone should take lowdose aspirin to reduce stroke risks. This is an incorrect choice.Aspirin is a medication that can prevent blood clots from forming and reduce the risk of ischemic stroke (caused by a blocked artery in the brain). However, aspirin is not suitable for everyone and can have side effects such as bleeding and stomach ulcers. Aspirin should only be taken under the guidance of a health care provider who can weigh the benefits and risks for eachindividual.
D. Annual endarterectomy screening exams are essential.
Annual endarterectomy screening exams are essential. This is an incorrect choice.Endarterectomy is a surgical procedure that removes plaque from the carotid arteries (the main arteries that supply blood to the brain). This can prevent or treat carotid artery disease, which is a risk factor for ischemic stroke. However, endarterectomy is not a screening exam; it is aninvasive treatment that has its own risks and complications. Endarterectomy is only recommended for people who have severe narrowing of the carotid arteries or who have had symptoms of a transient ischemic attack (TIA) or minor stroke.
E. Avoiding excess sodium, limiting alcohol, and exercising regularly decrease risks for
A nurse is monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply
(Select All that Apply.)
A. asystole
Asystole is incorrect because it is a cardiac arrest, not a sign of increased intracranial pressure (ICP).
B. hypotension
Hypotension is correct because it indicates that the brain is losing its ability to regulate blood pressure due to increased ICP.
C. widening pulse pressure
Widening pulse pressure is correct because it reflects the difference between systolic and diastolic blood pressure, which increases as the brain tries to maintain cerebral perfusion despite increased ICP.
D. bradycardia and bounding pulse
Bradycardia and bounding pulse are correct because they are signs of Cushing's triad, a classic manifestation of increased ICP that results from increased vagal stimulation and decreased sympathetic activity.
E. uneven breathing