The nurse is caring for a patient recovering from an ischemic stroke.
What intervention best addresses a potential complication after an ischemic stroke?
Keep a urinary catheter in place for the entire duration of recovery.
Provide three larger meals rather than frequent small meals.
Limit the intake of insoluble fiber.
Teach the patient to perform deep breathing and coughing exercises.
The Correct Answer is D
Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.
Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Herpes simplex virus encephalitis is a severe condition that requires immediate treatment. The most common medication used for this condition is acyclovir, which is administered intravenously. Acyclovir works by inhibiting the replication of the virus, thereby reducing the severity and duration of the infection.
Choice B rationale
Cyclosporine is an immunosuppressive medication that is often used to prevent organ rejection after transplantation. It is not typically used in the treatment of viral infections such as herpes simplex virus encephalitis.
Choice C rationale
Without specific information about “Medication C”, it’s difficult to provide a rationale.
However, it’s important to note that the treatment of herpes simplex virus encephalitis typically involves antiviral medications, with acyclovir being the most commonly used.
Choice D rationale
Similar to Choice C, without specific information about “Medication D”, providing a rationale is challenging. As mentioned, the standard treatment for herpes simplex virus encephalitis is acyclovir.
Correct Answer is C
Explanation
Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.
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