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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.
Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.
Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.
Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.
Correct Answer is D
Explanation
Choice A rationale: Addressing the obstruction and restoring urinary flow is a priority to prevent complications.
Choice B rationale: Managing pain caused by the stone obstruction is essential for the client's comfort and well-being.
Choice C rationale: Preventing urinary stasis and subsequent infection is crucial to avoid sepsis.
Choice D rationale: Education about prevention, though important, might have a lower priority compared to addressing immediate complications like obstruction and pain.
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