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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: This is the correct answer. It corresponds to 300 mg of the drug ((300x 5)/250).
Choice B rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 200 mg of amoxicillin trihydrate, which is less than the prescribed dose of 300 mg.
Choice C rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 60 mg of amoxicillin trihydrate, which is not enough to treat an oral infection.
Choice D rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 250 mg of amoxicillin trihydrate, which is less than the prescribed dose of 300 mg.
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Correct Answer is A
Explanation
Choice A rationale: This instruction helps to promote airflow and prevent moisture accumulation, aiding in vaginitis recovery.
Choice B rationale: Yogurt with live cultures containing lactobacilli can actually help restore the natural balance of bacteria in the vagina and can be beneficial for some types of vaginitis.
Choice C rationale: Oral contraceptives are not a treatment for vaginitis and do not impact the condition.
Choice D rationale: Douching can disrupt the vaginal pH and natural bacterial balance, potentially exacerbating vaginitis.
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