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 C

Explanation

Choice A rationale: This question is not relevant to BPH, as erectile dysfunction is not a common complication of this condition. Erectile dysfunction can have other causes, such as cardiovascular disease, diabetes, medications, psychological factors, or aging.

Choice B rationale: This question is not relevant to BPH, as penile discharge is not a symptom of this condition. Penile discharge can indicate an infection, such as sexually transmitted diseases, urinary tract infections, or prostatitis.

Choice C rationale: BPH is a condition that causes enlargement of the prostate gland, which can obstruct the flow of urine and cause symptoms such as difficulty in starting or stopping urination, weak or intermittent stream, dribbling, and incomplete bladder emptying. Asking about the force of the urinary stream can help assess the severity of BPH and the need for treatment.

Choice D rationale: This question is not relevant to BPH, as sexual function is not directly affected by this condition. However, some men with BPH may experience reduced libido or satisfaction due to urinary symptoms or psychological distress.

A. BSE will reduce the risk of dying from breast cancer. B. BSE should be done daily while taking a bath or shower. C. Performing BSE after the menstrual period is more comfortable. D. Annual mammograms should be scheduled in addition to BSE.

Correct Answer is C

Explanation

Choice A rationale: BSE will not reduce the risk of dying from breast cancer, but it may help you detect breast cancer earlier, when it is more treatable.

Choice B rationale: BSE should be done once a month, preferably at the same time each month. For women who have menstrual periods, the best time to do BSE is a few days after the period ends, when the breasts are less tender and swollen. For women who do not have menstrual periods, such as those who are pregnant, breastfeeding, or postmenopausal, they can choose a fixed date, such as the first day of each month, to do BSE.

Choice C rationale: For women who have menstrual periods, the best time to do BSE is a few days after the period ends, when the breasts are less tender and swollen. For women who do not have menstrual periods, such as those who are pregnant, breastfeeding, or postmenopausal, they can choose a fixed date, such as the first day of each month, to do BSE.

Choice D rationale: Annual mammograms are recommended for women aged 40 and older, or earlier if they have a high risk of breast cancer and not all women. Women aged less than 30 years should undergo breast ultrasound instead.

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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?

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