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","B","C","F"]
No explanation
Correct Answer is A
Explanation
A. A GCS score of 3 for eye opening indicates that the client opens their eyes in response to speech. This accurately reflects the client's level of responsiveness.
B. A GCS score of 5 for motor response indicates that the client localizes pain or can follow simple motor commands. However, this does not fully encapsulate the most appropriate conclusion, given the specific GCS score for eye opening.
C. A total GCS score of 13 (3 for eye opening, 5 for verbal response, and 5 for motor response) suggests mild impairment, not unconsciousness. Unconsciousness is typically indicated by a GCS score of 8 or below.
D. A GCS score of 5 for verbal response indicates the client is oriented and can respond verbally, so they are capable of making vocal sounds.
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