A 70year old client diagnosed with a hemorrhagic stroke was admitted 1 day ago. His
medical history includes hypertension, osteoarthritis, and type 2 diabetes. He has right sided
paralysis, garbled speech, and a weak cough reflex. This morning he is restless. Vital signs are Blood Pressure 160/80, pulse 110, respirations 24, oxygen saturation 90% Which of the following Interventions will the nurse take to avoid complications? Select all that apply
Select All that Apply)
Apply oxygen
Monitor blood pressure
Implement seizure precautions
Provide oral fluids
Turn the client twice each shift
Correct Answer : A,B,C,F
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Complete darkness at night can increase confusion and agitation in clients with Alzheimer's disease. The room should have adequate lighting and a night light to help orient the client and prevent falls.
B. Incorrect. Suction equipment is not necessary for clients with Alzheimer's disease unless they have respiratory problems or difficulty swallowing. Suction equipment can be noisy and frightening for clients with cognitive impairment and should be avoided unless indicated.
C. Incorrect. A walker or cane may be helpful for clients with Alzheimer's disease who have mobility issues, but it is not an essential item to include in the room. A walker or cane can also pose a tripping hazard or be used as a weapon by agitated clients.
D. Correct. Clocks, calendar, family photos are appropriate items to include in the room of a client with Alzheimer's disease. They can help the client maintain orientation to time, place, and person, and provide comfort and familiarity.
Correct Answer is ["He is now quiet and appears sleepy."]
Explanation
He is now quiet and appears sleepy. This is correct because it indicates a change in the level of consciousness, which could be a sign of increased intracranial pressure or bleeding in the brain.
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