The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Perform active range of motion three times daily.

Maintain the head of bed in a flat or 30 degree position.

Teach measures to avoid the Valsalva maneuver.

Monitor for Battle's sign every four hours.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.

Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.

Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.

Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.

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Correct Answer is A

Explanation

Choice A rationale: An allergy to sulfa drugs is important as some diabetes medications, like sulfonylureas, contain components related to sulfa drugs, which could cause an allergic reaction in susceptible individuals.

Choice B rationale: Smoking cessation and lifestyle history are important but might not directly impact initial diabetes treatment options.

Choice C rationale: Numbness in the soles of the feet might indicate neuropathy, a common complication of diabetes, but is not directly related to the choice of initial treatment.

Choice D rationale: While obesity is a risk factor for Type 2 diabetes, it's less critical for immediate treatment decisions compared to drug allergies that could impact medication choices.

A. Use of hormone therapy (HT) B. Irregularities in the menstrual cycle C. Changes in secondary sex characteristics D. Potential complication of infertility

Correct Answer is D

Explanation

Choice A rationale: Hormone therapy (HT) is used to treat menopausal symptoms, not PID.

Choice B rationale: Irregularities in the menstrual cycle is not a common complications of PID.

Choice C rationale: Changes in secondary sex characteristics is not a common complications of PID.

Choice D rationale: Pelvic inflammatory disease (PID) is an infection of the female reproductive organs that can cause scarring and damage to the fallopian tubes, ovaries, and uterus. This can lead to ectopic pregnancy, chronic pelvic pain, and infertility.

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The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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