The nurse is caring for a client who suffered a hemorrhagic stroke. In order to prevent increased intracranial pressure, the client should be placed in which position for the first 72 hours after the onset of a stroke?

The client's head should be turned to the side with the head of the bed elevated 60 degrees.

The client's head should be placed on a flat pillow with the foot of the bed higher than the head.

The client should be placed in dorsal recumbent with the head placed on pillows for comfort.

The head of the bed should be elevated 30 degrees with the head in neutral midline position.

Answer and Explanation

The Correct Answer is D

A. The client's head should be turned to the side with the head of the bed elevated 60 degrees. Elevating the head of the bed too high can cause a decrease in venous return, which can increase intracranial pressure.

B. The client's head should be placed on a flat pillow with the foot of the bed higher than the head. This position would not help with reducing intracranial pressure and may worsen it.

C. The client should be placed in dorsal recumbent with the head placed on pillows for comfort. This position does not provide optimal head elevation to decrease intracranial pressure.

D. The head of the bed should be elevated 30 degrees with the head in neutral midline position. A head elevation of 30 degrees with the head in a neutral midline position is ideal for promoting venous drainage from the brain, which helps reduce intracranial pressure.

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Correct Answer is D

Explanation

A. “There is some swelling in your right leg that is making you feel this way.” Swelling would typically cause discomfort or pressure, but it would not be responsible for the sensation of pain in the amputated limb.

B. "Your brain is responding to being inactive from the surgery." This answer does not address the real cause of the pain, which is related to the brain's continued perception of the missing limb.

C. "Don't worry about your right foot. The pain will go away within a few days." Phantom limb pain is a common phenomenon after amputation and may persist long-term. Dismissing it is not appropriate.

D. "Your brain is still receiving impulses about your right foot." This is an accurate explanation for phantom limb pain. After amputation, the brain may still interpret sensations from the absent limb, causing pain or discomfort in the "missing" foot.

A. Decerebrate posturing B. Decorticate posturing C. Flexion withdrawal D. Localization of pain

Correct Answer is B

Explanation

A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.

B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.

C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.

D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.

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The nurse is caring for a client who suffered a hemorrhagic stroke. In order to prevent increased intracranial pressure, the client should be placed in which position for the first 72 hours after the onset of a stroke?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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