The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Perform active range of motion three times daily.

Maintain the head of bed in a flat or 30 degree position.

Teach measures to avoid the Valsalva maneuver.

Monitor for Battle's sign every four hours.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.

Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.

Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.

Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.

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Correct Answer is B

Explanation

Choice A rationale: While joint deformities are concerning in RA, the immediate attention would be required for an acute, red, hot, swollen joint which could indicate an active inflammatory process.
Choice B rationale: Redness, heat, and swelling in a joint are signs of an acute flare in rheumatoid arthritis and might require urgent intervention to manage the inflammation.
Choice C rationale: Puffy-looking areas behind the knee might indicate joint involvement but might not require immediate attention as much as an acutely inflamed joint.
Choice D rationale: Jaw pain while eating can be a symptom of TMJ involvement in RA, but an acutely inflamed joint would generally take precedence.

A. Smokes 1 pack of cigarettes per day B. Drinks one alcoholic beverage per day C. Large body stature D. History of bone fracture during childhood

Correct Answer is A

Explanation

Choice A rationale: Smoking is a risk factor for osteoporosis as it can interfere with calcium absorption and decrease bone density.

Choice B rationale: Moderate alcohol consumption isn't a significant risk factor for osteoporosis.

Choice C rationale: Generally, having a larger body stature is not considered a significant risk factor for osteoporosis.

Choice D rationale: While fractures during childhood can affect bone health, they might not necessarily predict osteoporosis risk in adulthood.

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The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first?

Correct Answer is B

Explanation

A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

Correct Answer is A

Explanation

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