A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Choice A reason: Placing the chair by the bed is preparatory but not immediate after sitting up. Prolonged bedrest risks orthostatic hypotension from reduced plasma volume and baroreceptor sensitivity. Assessing the client’s response ensures stability before transfer, preventing falls, making this less urgent than evaluating for dizziness or hypotension.

Choice B reason: Supporting the client when rising is premature before assessing their response to sitting. Bedrest causes deconditioning, increasing orthostatic hypotension risk, leading to dizziness or syncope. Determining how the client feels confirms cardiovascular stability, preventing falls during transfer due to blood pressure drops.

Choice C reason: Determining how the client feels assesses for orthostatic hypotension, common post-bedrest due to reduced venous return and baroreceptor dysfunction. Dizziness or lightheadedness signals syncope risk during transfer. This ensures cardiovascular stability, prioritizing safety before physical support, addressing physiological changes from prolonged immobility.

Choice D reason: Offering non-skid socks prevents falls during ambulation but is secondary to assessing sitting response. Bedrest heightens hypotension risk, and ensuring the client is not dizzy takes precedence to avoid syncope. Socks are a later safety measure, making this less immediate than evaluating physiological stability.

Choice A reason: Imbalanced nutrition is unrelated to 150 mL residual urine, which indicates incomplete bladder emptying, often from detrusor dysfunction or obstruction. Nutrition affects overall health but does not cause retention. Residual urine increases infection risk due to stasis, making nutrition an irrelevant nursing problem for this urinary issue.

Choice B reason: Deficient fluid volume suggests dehydration, reducing urine output, not causing high residual volumes. Residual urine (150 mL) indicates retention from impaired bladder emptying, not fluid deficit. Hydration prevents stasis, but infection risk from retained urine is more immediate, as bacteria proliferate in stagnant urine.

Choice C reason: Residual urine of 150 mL signifies incomplete bladder emptying, often from obstruction or neurogenic bladder, leading to urinary stasis. This fosters bacterial growth, increasing urinary tract infection (UTI) risk. Including “risk for infection” addresses this pathophysiological concern, guiding interventions like catheterization to reduce infection likelihood.

Choice D reason: Urinary incontinence involves involuntary leakage, not retention, where the bladder fails to empty, as seen with 150 mL residual urine. Retention results from outflow obstruction or weak detrusor, distinct from incontinence’s loss of control, making this nursing problem inappropriate for the client’s condition.