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 C
No explanation
Correct Answer is B
Explanation
A. Complete a vascular assessment: Although meningococcal meningitis can lead to complications such as septicemia, which affects vascular status, assessing cranial nerves is more immediately pertinent. Identifying neurological deficits can provide crucial information about the extent and location of meningitis-related brain involvement.
B. Assess the cranial nerves: This is the correct action to initiate next. Meningococcal meningitis can affect the central nervous system, leading to cranial nerve involvement. Assessing the cranial nerves helps to identify any neurological deficits early, which is crucial for guiding treatment and monitoring progression.
C. Decrease environmental stimuli: While this is important for managing a patient with meningitis to prevent further neurological irritation, it is not as immediate a priority as assessing cranial nerve function to detect any neurological impairment.
D. Administer an antipyretic: Fever management is important, but it is not the next immediate priority after initiating droplet precautions. Assessing cranial nerves provides vital information about the patient's neurological status, which directly impacts immediate clinical decisions.
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