A client who has experienced an ischemic stroke has been admitted to the medical unit. The client’s family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse’s response to the family?

To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks

The client should mobilize as soon as physically able

The client should remain on bed rest until the client expresses a desire to mobilize

Lack of mobility will greatly increase the client’s risk of stroke recurrence

Answer and Explanation

The Correct Answer is B

Reasoning:

Choice A reason: Limiting bed rest to 4 weeks to prevent contractures and atrophy is not the primary principle. While prolonged immobility causes these issues, early mobilization post-stroke improves recovery and prevents complications like thromboembolism, making immediate mobilization the key focus rather than a time limit.

Choice B reason: Mobilizing as soon as physically able is critical post-ischemic stroke to enhance recovery. Early mobilization improves circulation, prevents thromboembolism, maintains muscle strength, and promotes neuroplasticity, reducing disability. This principle counters the family’s insistence on bed rest, which increases complication risks and hinders recovery.

Choice C reason: Waiting for the client to express a desire to mobilize delays recovery. Stroke patients may lack initiative due to neurological deficits or depression. Early mobilization, guided by physical ability, prevents complications like deep vein thrombosis and supports rehabilitation, making patient desire a poor criterion.

Choice D reason: Lack of mobility does not directly increase stroke recurrence risk, which is more tied to vascular risk factors like hypertension or diabetes. However, immobility increases complications like thromboembolism, which could indirectly contribute to stroke. Early mobilization is the priority to enhance overall recovery.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Confusion may occur in SIADH due to hyponatremia-induced cerebral edema, but diarrhea is not a typical sign of fluid overload. Diarrhea causes fluid loss, which is opposite to the water retention seen in SIADH, making this combination less indicative of fluid overload compared to cardiovascular or respiratory signs.

Choice B reason: Hypertension may occur in SIADH due to fluid overload, but weight gain without edema is less specific. SIADH often causes subtle fluid retention without overt edema, but weight gain alone does not fully indicate fluid overload, as it lacks the respiratory or cardiovascular specificity of dyspnea and hypertension.

Choice C reason: Pulmonary congestion may indicate fluid overload in SIADH, as excess water can lead to pulmonary edema. However, muscle cramps are more related to hyponatremia than fluid overload itself. This combination is less precise than dyspnea and hypertension for identifying fluid overload in this context.

Choice D reason: Dyspnea and hypertension are key indicators of fluid overload in SIADH. Excessive ADH causes water retention, increasing blood volume, which raises blood pressure. Fluid accumulation in the lungs can cause dyspnea, reflecting pulmonary edema, a serious complication of fluid overload in SIADH, making this the most accurate finding.

A. Fluid intake is less than 2,500 ml/day B. Heart rate is 126 beats/minute C. Blood pressure is 90/50 mm Hg D. Urine output measures more than 200 ml/hour

Correct Answer is A

Explanation

Reasoning:

Choice A reason: Effective treatment of diabetes insipidus, typically with desmopressin, restores ADH function, reducing excessive urine output and thirst. Fluid intake below 2,500 ml/day indicates improved water reabsorption in the kidneys, normalizing fluid balance and reducing polyuria, which is a key sign of successful management of this condition.

Choice B reason: A heart rate of 126 beats/minute indicates tachycardia, often a sign of dehydration or hypovolemia in untreated diabetes insipidus. Effective treatment should normalize heart rate by correcting fluid balance, so persistent tachycardia suggests ongoing fluid loss and ineffective treatment, not a successful therapeutic outcome.

Choice C reason: Blood pressure of 90/50 mm Hg indicates hypotension, which can result from severe dehydration in untreated diabetes insipidus. Effective treatment should stabilize blood pressure by restoring fluid volume through improved water reabsorption, making low blood pressure an indicator of poor treatment response rather than success.

Choice D reason: Urine output exceeding 200 ml/hour reflects polyuria, a primary symptom of untreated diabetes insipidus due to ADH deficiency. Effective treatment reduces urine output by enhancing renal water reabsorption, so high urine output indicates persistent disease activity, not a successful response to therapy.

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A client who has experienced an ischemic stroke has been admitted to the medical unit. The client’s family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse’s response to the family?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload?

Correct Answer is D

Explanation

Which outcome indicates that treatment of a client with diabetes insipidus has been effective?

Correct Answer is A

Explanation

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