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
Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.
Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.
Correct Answer is A
Explanation
Choice A rationale
The best way to determine if a patient can safely and effectively self-administer medications is to ask the patient to demonstrate the instillation of the medications. This allows the nurse to directly observe the patient’s technique, identify any errors, and provide immediate feedback and instruction. It also gives the patient an opportunity to ask questions and clarify any misunderstandings. This method is often referred to as the “show-back” or “teach-back” method and is widely used in patient education to confirm understanding and competency.
Choice B rationale
While assessing the patient for any previous inability to self-manage medications can provide useful information, it does not directly assess the patient’s ability to self-administer the new eye medications. Previous difficulties may be due to factors that do not apply to the current situation, such as complex medication regimens, cognitive impairment, or lack of resources.
Choice C rationale
Although the patient accurately describing the directions for administering the medications indicates that the patient understands the instructions, it does not necessarily mean that the patient can perform the task correctly. Physical limitations, dexterity issues, or misunderstanding of the instructions can still result in incorrect administration.
Choice D rationale
Assessing the patient’s functional status can provide valuable information about the patient’s overall ability to perform activities of daily living, including medication management.
However, it does not specifically assess the patient’s ability to self-administer eye medications.
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