A clients ICP is 34 mm Hg, CPP 65 mm Hg. What shou

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A client’s ICP is 34 mm Hg, CPP 65 mm Hg. What should the nurse do next with appropriate orders?

A. No action required B. Suction the client C. Place client supine and flat D. Administer mannitol 1-2 g/kg IV

Correct Answer: D

Rationale: ICP >15, CPP <70 (text note) require intervention. Mannitol (D) reduces cerebral edema.

Joint Commission’s eight core measures for stroke care include which? (SATA)

A. Thrombolytic therapy (<4 hr) B. Discharged on statin C. VTE prophylaxis D. All the Above

Correct Answer: D

Rationale: Core measures: thrombolysis (A), statins (B), VTE (C), antithrombotic (D); E is partial.

Interventions to prevent unilateral neglect in right-sided hemiplegia include?

A. Dress affected side first B. Wear high-top sneakers C. Approach from affected side D. Attach footboard

Correct Answer: A

Rationale: Dressing affected side first (A) encourages attention to neglected side.

The nurse’s priority action for a client with stroke symptoms?

A. Heparin IV B. Ask about headaches C. 1000 mg aspirin D. Time since symptoms

Correct Answer: D

Rationale: Time of onset (D) determines tPA window.

Joint Commission stroke measures include? (SATA)

A. Discharge with antithrombotic B. All get anticoagulation C. Antithrombotic by stay end D.

Correct Answer: A

Rationale: Antithrombotic discharge (A) is a core measure.

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