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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Adenomas are benign tumors that originate from glandular tissue, such as the endometrium, the inner lining of the uterus.
Choice B rationale: Leiomyomas, also known as fibroids, are benign tumors that arise from the smooth muscle cells of the myometrium, the middle layer of the uterine wall. They are the most common type of uterine tumors, affecting up to 80% of women by age 50. They can cause symptoms such as heavy menstrual bleeding, pelvic pain, pressure, and infertility.
Choice C rationale: Endometriosis is a condition where endometrial tissue grows outside the uterus, causing inflammation and pain.
Choice D rationale: Adenomyosis is a condition where endometrial tissue invades the myometrium, causing enlargement and distortion of the uterus.
Correct Answer is A
Explanation
Choice A rationale: The correct answer is 5 units/hour. To calculate the units of insulin per hour, we need to use the following formula: units of insulin per hour = (units of insulin in the bag / volume of the bag) x infusion rate
Plugging in the given values, we get:
units of insulin per hour = (50 / 100) x 10 units of insulin per hour = 0.5 x 10
units of insulin per hour = 5
Therefore, the client is receiving 5 units of insulin every hour.
Choice B rationale: This is incorrect because it assumes that the infusion rate is equal to the units of insulin per hour, which is not true.
Choice C rationale: This is incorrect because it multiplies the units of insulin in the bag by the infusion rate, which is too high.
Choice D rationale: This is incorrect because it adds the units of insulin in the bag and the infusion rate, which is also too high.
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