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 D

Explanation

Choice A rationale: These are symptoms of advance renal failure. Stomatitis and diarrhea are signs of uremia, which is the accumulation of waste products in the blood.

Choice B rationale: Dyspnea and anuria are signs of fluid overload and kidney shutdown and indicate advanced renal failure.

Choice C rationale: Confusion and vomiting are signs of acidosis and electrolyte disturbances and occur in advanced stages of renal failure.

Choice D rationale: One of the early symptoms of renal insufficiency is nocturia, which is the need to urinate frequently at night. This occurs because the kidneys are unable to concentrate urine during the day and produce more urine at night. Another early symptom is oliguria, which is the production of less than 400 mL of urine per day. This occurs because the kidneys are unable to excrete enough urine to maintain fluid balance.

A. A 58-year-old client with gastrointestinal reflux disease B. A 65-year-old client with mild emphysema C. A 72-year-old client with hyperthyroidism D. A 48-year-old client with hypertension

Correct Answer is D

Explanation

Choice A rationale: Gastrointestinal reflux disease is not typically a contraindication for sumatriptan.

Choice B rationale: Mild emphysema is not typically a contraindication for sumatriptan.

Choice C rationale: Hyperthyroidism is not typically a contraindication for sumatriptan.

Choice D rationale: Sumatriptan, a medication used for migraines, may elevate blood pressure, so it would be questionable for a client with hypertension.

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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

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