A nurse is caring for a client who experienced severe head trauma. The client's partner asks the nurse why they are concerned about the mean arterial pressure (MAP). The nurse should explain that MAP determines which of the following?
Cerebral blood flow
The client's intake and output needs
Regulation of blood pressure
Resorption of cerebrospinal fluid
The Correct Answer is A
A. Cerebral blood flow. MAP is crucial for maintaining adequate cerebral perfusion pressure, ensuring enough blood flow to the brain.
B. The client's intake and output needs. MAP does not directly influence intake and output needs; it is more directly related to blood flow and tissue perfusion.
C. Regulation of blood pressure. MAP is a measure of average blood pressure but not a regulator of it.
D. Resorption of cerebrospinal fluid. CSF resorption is not directly influenced by MAP; it’s regulated by intracranial pressure and other factors.
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Correct Answer is D
Explanation
A. Schedule deep tissue massage with physical therapy. Massaging the area is contraindicated in cases of suspected deep vein thrombosis (DVT), as it can dislodge the clot, leading to a pulmonary embolism.
B. Monitor Homan's sign. Homan’s sign (pain in the calf upon dorsiflexion) is no longer considered a reliable or safe assessment for DVT due to the risk of dislodging a clot.
C. Obtain platelet aggregation studies. Platelet aggregation studies are not specific to diagnosing a DVT; instead, imaging is preferred.
D. Arrange for a venous duplex ultrasound. A venous duplex ultrasound is a non-invasive test that can confirm the presence of a DVT in the affected extremity.
Correct Answer is A
Explanation
A. To prevent blood clotting: Aspirin is an antiplatelet agent, and it reduces blood clot formation, which helps prevent further cardiac events after an MI.
B. To reduce inflammation: Although aspirin has anti-inflammatory properties, this is not the primary reason for its use in post-MI clients.
C. To prevent fever: Aspirin can reduce fever, but this is not its purpose in MI prevention.
D. To provide analgesia: Aspirin can relieve pain, but in this context, it is used to prevent blood clotting, not as an analgesic.