A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?

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.

Choice A reason: Gradual onset of several hours is not a manifestation of a hemorrhagic stroke. A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the surrounding tissue. This usually happens suddenly and without warning, and can cause rapid deterioration of the client's condition.

Choice B reason: Maintains consciousness is not a manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause increased intracranial pressure, which can compress the brain and impair its function. This can lead to loss of consciousness, coma, or death.

Choice C reason: Sudden severe headache is a manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause intense pain in the head, neck, or face, due to the pressure and irritation of the bleeding. The headache may be described as "the worst headache of my life" or "thunderclap headache".

Choice D reason: History of neurologic deficits lasting less than 1 hr. is not a manifestation of a hemorrhagic stroke. This is a characteristic of a transient ischemic attack (TIA), which is also known as a mini-stroke. A TIA occurs when a blood clot temporarily blocks an artery in the brain, causing temporary symptoms such as weakness, numbness, vision loss, or speech difficulty. A TIA does not cause permanent damage to the brain, but it is a warning sign of a possible future stroke.