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: 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.
Correct Answer is D
Explanation
Choice A rationale: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.
Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.
Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.
Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.
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