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.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Choice A rationale: The lab results and clinical picture, such as weight loss, anorexia, and high blood glucose levels, point more toward a hyperglycemic state rather than severe hypoglycemia.
Choice B rationale: The client's elevated blood glucose levels, weight loss, and anorexia suggest a hyperglycemic state, possibly hyperosmolar hyperglycemic state, which requires fluid management and insulin to address the severe dehydration and high blood glucose levels.
Choice C rationale: Although high glucose levels are evident, the absence of significant acidosis (as seen in diabetic ketoacidosis) and extreme ketosis makes this diagnosis less likely.
Choice D rationale: The lab values and clinical presentation do not strongly align with a primary respiratory acidosis diagnosis, which typically involves changes in pH and carbon dioxide levels.
Correct Answer is D
Explanation
Choice A rationale: This is incorrect.
Choice B rationale: This describes metabolic syndrome, a collection of risk factors, but not a direct complication of type 1 diabetes.
Choice C rationale: This describes hyperosmolar hyperglycemic state, which is more characteristic of severe hyperglycemia but not the most common complication in type 1 diabetes.
Choice D rationale: Diabetic ketoacidosis (DKA) is a frequent and serious complication in type 1 diabetes, characterized by ketone formation due to the absence of insulin, leading to metabolic acidosis and potential life-threatening symptoms.
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