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
Explanation
Bruising over the cheek is a sign of facial trauma, not basilar skull fracture.
Missing teeth is a sign of dental injury, not basilar skull fracture.
Discoloration behind the left ear, also known as Battle's sign, is a sign of basilar skull fracture, as blood accumulates in the mastoid process due to a fracture in the temporal bone.
Bleeding from the nose is a sign of nasal trauma, not basilar skull fracture.
Correct Answer is B
No explanation
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