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","C","D","E"]
Explanation
Choice A rationale
Venous thromboembolism (VTE) is a serious complication that can occur in comatose patients. Immobility is a major risk factor for VTE, and comatose patients are often immobile. Therefore, nurses should be vigilant for signs of VTE, such as swelling, pain, or redness in the extremities.
Choice B rationale
Hemorrhage is not typically a direct complication of coma. However, the underlying cause of the coma, such as a traumatic brain injury, could potentially lead to hemorrhage.
Choice C rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can occur in comatose patients due to prolonged immobility. Regular movement and physiotherapy can help prevent this complication.
Choice D rationale
Pressure ulcers, also known as bedsores, are a common complication in comatose patients. They occur when there is prolonged pressure on the skin, usually over bony areas. Regular turning and good skin care can help prevent pressure ulcers.
Choice E rationale
Pneumonia is a common complication in comatose patients, often resulting from aspiration (inhaling food, stomach acid, or saliva into the lungs)2. Nurses should be vigilant for signs of pneumonia, such as fever, cough, and difficulty breathing.
Correct Answer is C
Explanation
Choice A rationale
While assessing visual acuity may be part of a comprehensive eye examination, it would not specifically address distortions noted on the Amsler grid.
Choice B rationale
Tonometry testing is used to measure the pressure inside the eye and is typically used in the diagnosis of glaucoma. It would not specifically address distortions noted on the Amsler grid.
Choice C rationale
Distortions when looking at the Amsler grid can be a sign of macular degeneration16. Therefore, arranging for the client to be assessed for macular degeneration would be the appropriate action16.
Choice D rationale
While age-related changes in vision can occur, distortions when looking at the Amsler grid are not typically considered a normal age-related change16. Therefore, reassuring the client that this is an age-related change in vision would not be the appropriate action16.
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