What are some of the nursing interventions for the patient with a hemorrhagic stroke?
Encouraging lots of visitors
Out of bed with lots of walking in the halls
Nonstimulating, nonstressful environment; dim lighting, visitors are restricted
All of the above
The Correct Answer is C
Choice A: Encouraging lots of visitors is incorrect because it can increase the stimulation, stress, and noise level for the patient with a hemorrhagic stroke. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. This can cause increased intracranial pressure, brain damage, or death. The patient needs to rest and avoid any factors that can raise their blood pressure or worsen their condition.
Choice B: Out of bed with lots of walking in the halls is incorrect because it can also increase the risk of complications for the patient with a hemorrhagic stroke. The patient may have impaired mobility, balance, or coordination due to the brain injury. They may also have weakness, numbness, or paralysis on one side of the body. The patient needs to be assessed and assisted with their activity level and safety precautions.
Choice C: Nonstimulating, nonstressful environment; dim lighting, visitors are restricted is correct because it can help reduce the intracranial pressure and promote healing for the patient with a hemorrhagic stroke. The patient needs to have a quiet, calm, and comfortable environment that minimizes sensory input and emotional distress. The patient also needs to have limited and supervised visitors who are supportive and respectful of their needs.
Choice D: All of the above are incorrect because only choice c) is appropriate for the patient with a hemorrhagic stroke. Choices a) and b) are contraindicated and can harm or hinder the patient's recovery. The nurse should provide individualized and evidence-based care for the patient with a hemorrhagic stroke and follow the guidelines and protocols for stroke management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Headache is not a late sign of intracranial pressure, but rather an early sign of increased pressure or irritation of the meninges.
Choice B: Confusion is not a late sign of intracranial pressure, but rather an early sign of impaired cognition or orientation.
Choice C: Stupor to coma is a late sign of intracranial pressure, as it indicates a severe deterioration of consciousness or brain function.
Choice D: Weakness is not a late sign of intracranial pressure, but rather a sign of focal neurological deficit or hemiparesis.
Correct Answer is A
Explanation
Choice A: Thickened liquids or pureed diet is correct because it can prevent aspiration, choking, or malnutrition in stroke patients. A stroke can impair the patient's ability to swallow, chew, or control their tongue and mouth movements. This can cause food or liquids to enter the airway instead of the esophagus, leading to pneumonia or death. A thickened liquid or pureed diet consists of foods that are smooth, soft, and easy to swallow. The nurse should assess the patient's swallowing function and provide appropriate food and drink consistency.
Choice B: Regular diet is incorrect because it can be unsafe or unsuitable for stroke patients. A regular diet consists of foods that are solid, crunchy, or sticky and require normal chewing and swallowing abilities. The nurse should not give a regular diet to a stroke patient unless they have passed a swallowing evaluation and have no signs of dysphagia.
Choice C: Renal diet is incorrect because it is not specific to stroke patients. A renal diet is designed for patients with kidney disease or failure. It limits the intake of sodium, potassium, phosphorus, and protein to reduce the workload and waste products of the kidneys. The nurse should not give a renal diet to a stroke patient unless they also have a kidney condition and a doctor's order.
Choice D: Cardiac diet is incorrect because it is not specific to stroke patients. A cardiac diet is designed for patients with heart disease or risk factors. It limits the intake of saturated fat, cholesterol, sodium, and sugar to lower the blood pressure and cholesterol levels and prevent further damage to the heart. The nurse should not give a cardiac diet to a stroke patient unless they also have a heart condition and a doctor's order.
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