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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "Diet and exercise is good for you and good for your heart." This statement is true, but it is not the appropriate nursing response. It does not address the client's concerns or provide any specific information about cardiac rehabilitation. It may also sound dismissive or patronizing to the client.
Choice B reason: "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." This statement is empathetic, but it is not the appropriate nursing response. It does not explain the purpose or benefits of cardiac rehabilitation. It may also sound unrealistic or optimistic to the client.
Choice C reason: "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." This statement is the appropriate nursing response. It acknowledges the client's condition and provides factual information about cardiac rehabilitation. It also emphasizes the positive outcomes of cardiac rehabilitation, such as improving physical function, reducing symptoms, and preventing further complications.
Choice D reason: "Your doctor is the expert here, and I'm sure he would only recommend what is best for you." This statement is respectful, but it is not the appropriate nursing response. It does not answer the client's question or provide any education about cardiac rehabilitation. It may also sound evasive or deferential to the client.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Epidemiology interprets legislation in the community is not a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology is not directly involved in interpreting legislation, but rather in providing evidence and recommendations that can inform policy-making and law-making.
Choice B reason: Epidemiology relates to the health status of a population is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology is the study of how diseases and other health-related factors are distributed and determined in populations. It helps the community health nurse to identify and monitor health problems, trends, and disparities in different groups and areas.
Choice C reason: Epidemiology analyzes and examines the root causes of health outcomes is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology uses various methods and tools to investigate and explain the causes and consequences of diseases and other health-related events. It helps the community health nurse to understand and address the complex and multifactorial factors that influence health, such as biological, environmental, social, behavioral, and economic factors.
Choice D reason: Epidemiology evaluates the effectiveness of nursing interventions is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology applies scientific principles and rigorous designs to assess and compare the outcomes and impacts of different interventions and programs on health. It helps the community health nurse to plan, implement, and evaluate evidence-based practices and policies that can improve health and quality of life.
Choice E reason: Epidemiology defines the burden of disease and determinants of health is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology measures and compares the frequency, severity, and impact of diseases and other health-related conditions on populations. It helps the community health nurse to prioritize and allocate resources, as well as to advocate for health equity and social justice.
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