A preceptor discussing stroke with a new nurse on the unit would tell the new nurse that which cardiac dysrhythmia is associated with cardiogenic embolic strokes?

Reasoning:

Choice A reason: Arranging for friends and family to sit with the client may provide comfort but does not directly prevent injury from agitation. Family presence cannot ensure physical safety during sudden movements, whereas padding side rails directly reduces harm from agitation-related impacts in head injury.

Choice B reason: Restraining the client increases agitation and injury risk in head-injured patients, as it can exacerbate distress and cause pressure injuries. Non-restrictive measures like padding are safer, reducing harm from agitation without compromising autonomy or worsening neurological status in this high-risk population.

Choice C reason: Padding side rails is the best intervention to prevent injury in an agitated client with a head injury. Agitation increases the risk of hitting bed rails, causing bruises or fractures. Padding absorbs impact, ensuring safety without restricting movement, addressing the immediate physical risk effectively.

Choice D reason: Administering opioids PRN may reduce pain but not agitation in head injury. Opioids can depress respiration and consciousness, potentially masking neurological changes or worsening ICP, making them less safe than padding side rails to prevent physical injury from agitation-related movements.

Reasoning:

Choice A reason: Placing the clock on the affected side (left in right-sided stroke) worsens hemianopsia issues, as the client cannot see the left visual field. This increases neglect and disorientation. Positioning items in the intact visual field helps the client compensate for the visual deficit effectively.

Choice B reason: Placing extremities in the client’s intact visual field (right side in right-sided stroke) compensates for left hemianopsia. This helps the client maintain awareness of their body, reducing neglect and injury risk, as they cannot see the left side, improving safety and sensory integration.

Choice C reason: Approaching from the impaired side (left in right-sided stroke) increases disorientation and neglect in hemianopsia. Approaching from the intact right side ensures the client can see and respond, improving communication and reducing startle or confusion caused by unseen approaches.

Choice D reason: Keeping lighting low may reduce glare but does not address hemianopsia’s visual field loss. Adequate lighting in the intact field enhances visibility of objects and extremities, aiding compensation for the deficit. Low lighting could increase disorientation in clients with visual impairments.