A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?

Monitoring vital signs and neurological status frequently.

Maintaining strict bed rest to minimize cerebral blood flow.

Administering anticoagulant medications as prescribed.

Assisting the client with active range of motion exercises.

Answer and Explanation

The Correct Answer is A

Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.

Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skincare, and comfort measures to the client.

Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.

Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.

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Correct Answer is D

Explanation

Choice A reason: A public health nurse is a nurse who works to improve the health and well-being of populations and communities, not specific workplaces. A public health nurse may focus on disease prevention, health promotion, environmental health, or emergency preparedness.

Choice B reason: A community nurse specialist is a nurse who has advanced education and training in a specific area of nursing practice, such as gerontology, oncology, or mental health. A community nurse specialist may work in various settings, such as hospitals, clinics, or schools, to provide specialized care and education to clients and families.

Choice C reason: A nurse clinician is a nurse who has expertise in clinical practice, research, and education. A nurse clinician may work in academic or clinical settings, such as universities, hospitals, or research centers, to develop and implement evidence-based practices and policies.

Choice D reason: An occupational health nurse is a nurse who works to protect and promote the health and safety of workers in various industries, such as manufacturing, mining, or construction. An occupational health nurse may provide services such as health assessment, injury prevention, emergency response, or wellness programs.

A. Deliver a clean voided urine specimen to the laboratory. B. Feed a client who has bilateral casts due to upper arm fractures. C. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. D. Obtain an extra box of tissues for a client who is concerned about running out of them.

Correct Answer is C

Explanation

Choice A reason: Delivering a urine specimen to the laboratory is not a priority task, as it does not affect the client's immediate health or safety. This task can be done later or delegated to another staff member.

Choice B reason: Feeding a client who has bilateral casts is an important task, as it helps the client meet their nutritional needs and prevents complications such as pressure ulcers. However, this task is not as urgent as monitoring blood glucose levels, as it can be done within a reasonable time frame without causing harm to the client.

Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin is a priority task, as it determines the dosage of insulin that the client needs to receive. Insulin is a high-alert medication that can cause serious adverse effects if given incorrectly. Therefore, this task should be done first by the AP who has been trained and certified to do so.

Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is a low-priority task, as it does not affect the client's physical or psychological well-being. This task can be done at any time or delegated to another staff member.

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