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)
Apply oxygen
Monitor blood pressure
Implement seizure precautions
Provide oral fluids
Turn the client twice each shift
Correct Answer : A,B,C,F
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Correct. Increasing fluid intake can help replenish cerebrospinal fluid (CSF) that was lost during the lumbar puncture, which can reduce the pressure difference between the brain and spinal cord that causes the headache.
B.Incorrect. Administering pain medication can help relieve the headache temporarily, but it does not address the underlying cause of CSF loss and pressure difference.
C. Incorrect. Darkening the client's room and closing the door can help reduce sensory stimuli that may aggravate the headache, but it does not address the underlying cause of CSF loss and pressure difference.
D. Incorrect. Elevating the head of the bed to 30 can worsen the headache by increasing the pressure difference between the brain and spinal cord, as gravity pulls more CSF away from the brain.
Correct Answer is B
No explanation
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