A client with homonymous hemianopsia resulting from a stroke has a disturbed sensory perception.
An appropriate nursing intervention to help the client learn to compensate for this deficit during the rehabilitation period would be to:

Choice A rationale

Restlessness and altered mental status are early signs of increasing intracranial pressure, resulting from cerebral edema compressing neural tissue and reducing oxygen supply to critical brain regions.

Choice B rationale

Widening pulse pressure is a later sign of increased intracranial pressure, indicating significant disruption of autonomic regulation and brainstem function. Early symptoms like restlessness occur first.

Choice C rationale

Fixed and dilated pupils signify severe and advanced intracranial pressure, often indicating brain herniation, which is a critical stage beyond initial compensatory mechanisms.

Choice D rationale

Tachycardia and hypotension are not hallmark signs of raised intracranial pressure. Bradycardia and hypertension align more closely with Cushing's triad, associated with late-stage intracranial hypertension. .

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.