The nurse notes that a client has ataxia. Which test does the nurse use to gain more information about this client's gait?

Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.

Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skin care, and comfort measures to the client.

Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.

Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.

Choice A reason: Providing total assistance with all ADLs is not an intervention that should be included in the client's plan. ADLs are activities of daily living, such as bathing, dressing, eating, and toileting. Providing total assistance with all ADLs can reduce the client's independence and self-esteem, and increase their dependence and learned helplessness. The nurse should encourage and assist the client to perform as much as they can by themselves and provide partial or intermittent assistance only when needed.

Choice B reason: Ordering a low-residue diet is not an intervention that should be included in the client's plan. A low-residue diet is a type of diet that limits foods that are high in fiber or indigestible material, such as whole grains, nuts, seeds, fruits, and vegetables. A low-residue diet may be recommended for clients who have inflammatory bowel disease (IBD), diverticulitis, or bowel obstruction, as it can reduce bowel frequency and irritation. However, it is not indicated for clients who have MS, unless they have other comorbidities that require it. A balanced diet that includes adequate fiber, fluids, and nutrients is more beneficial for clients who have MS.

Choice C reason: Encouraging the client to void every hour is not an intervention that should be included in the client's plan. Voiding every hour can be inconvenient and impractical for the client, and may not address their bladder problems effectively. MS can cause bladder dysfunction, such as urinary urgency, frequency, incontinence, or retention, due to nerve damage that affects bladder control. The nurse should assess the type and severity of the bladder dysfunction, and provide appropriate interventions, such as medication, catheterization, pelvic floor exercises, or bladder training.

Choice D reason: Instructing the client on daily muscle stretching is an intervention that should be included in the client's plan. Muscle stretching is a type of exercise that involves extending or elongating a muscle or group of muscles to their full length. Muscle stretching can help prevent or relieve muscle spasticity, stiffness, pain, or contractures that may occur in clients who have MS. The nurse should teach the client how to perform muscle stretching safely and correctly, and encourage them to do it daily or as prescribed.