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 D
Explanation
Choice D rationale
When assessing a patient with an altered level of consciousness, the nurse’s initial action should be to assess the patient’s response to pain. This is a fundamental part of the neurological examination and can provide valuable information about the patient’s level of consciousness and neurological function. Pain response can be assessed by applying a painful stimulus, such as a pinch, and observing the patient’s reaction.
Choice A rationale
Assessing the patient’s ability to follow complex commands is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. This assessment requires a higher level of cognitive function and may not be possible in a patient with significantly altered consciousness.
Choice B rationale
Assessing the patient’s judgment is an important part of the mental status examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. Like the ability to follow complex commands, judgment requires a higher level of cognitive function and may not be assessable in a patient with significantly altered consciousness.
Choice C rationale
Assessing the patient’s verbal response is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. The patient’s ability to speak and the content of their speech can provide important information about their neurological function, but this assessment may not be possible in a patient with significantly altered consciousness.
Correct Answer is A
Explanation
Choice A rationale
Eating food that is either very warm or very cold can trigger pain in individuals with trigeminal neuralgia. Therefore, if a client made this statement, it would indicate the need for further teaching.
Choice B rationale
Chewing on the unaffected side can help minimize episodes of pain in trigeminal neuralgia.
Choice C rationale
Rinsing the mouth if tooth brushing is too painful is a good strategy for managing trigeminal neuralgia.
Choice D rationale
Washing the face with cotton pads can help minimize episodes of pain in trigeminal neuralgia.
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