The nurse is caring for a client who suffered a hemorrhagic stroke. In order to prevent increased intracranial pressure, the client should be placed in which position for the first 72 hours after the onset of a stroke?

The client's head should be turned to the side with the head of the bed elevated 60 degrees.

The client's head should be placed on a flat pillow with the foot of the bed higher than the head.

The client should be placed in dorsal recumbent with the head placed on pillows for comfort.

The head of the bed should be elevated 30 degrees with the head in neutral midline position.

Answer and Explanation

The Correct Answer is D

A. The client's head should be turned to the side with the head of the bed elevated 60 degrees. Elevating the head of the bed too high can cause a decrease in venous return, which can increase intracranial pressure.

B. The client's head should be placed on a flat pillow with the foot of the bed higher than the head. This position would not help with reducing intracranial pressure and may worsen it.

C. The client should be placed in dorsal recumbent with the head placed on pillows for comfort. This position does not provide optimal head elevation to decrease intracranial pressure.

D. The head of the bed should be elevated 30 degrees with the head in neutral midline position. A head elevation of 30 degrees with the head in a neutral midline position is ideal for promoting venous drainage from the brain, which helps reduce intracranial pressure.

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Correct Answer is A

Explanation

A. Compartment syndrome. The client’s unrelieved pain, despite analgesics, and the presence of swelling distal to the cast are warning signs of compartment syndrome. This is a medical emergency that occurs when increased pressure within a closed muscle compartment reduces blood flow, leading to tissue damage and pain.

B. Muscle wasting. Muscle wasting typically occurs over time due to disuse and is not a sudden, acute complication like compartment syndrome.

C. Skin breakdown. Skin breakdown could occur from improper cast fitting or prolonged pressure, but it would not cause unrelieved pain in the same way as compartment syndrome.

D. Joint stiffness. Joint stiffness can occur in casted limbs after removal, but it is not an acute complication like compartment syndrome.

A. Inability to see objects on one side of the visual field B. Inability to perform a previously learned action C. Inability to repeat a simple sentence D. Inability to hear from the ear on the affected side

Correct Answer is B

Explanation

A. Inability to see objects on one side of the visual field: This describes hemianopsia, not apraxia.

B. Inability to perform a previously learned action: Apraxia is the loss of the ability to perform skilled movements or gestures despite having the desire and physical ability to do so.

C. Inability to repeat a simple sentence: This describes aphasia, specifically expressive or receptive aphasia.

D. Inability to hear from the ear on the affected side: This describes hearing loss, which is unrelated to apraxia.

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The nurse is caring for a client who suffered a hemorrhagic stroke. In order to prevent increased intracranial pressure, the client should be placed in which position for the first 72 hours after the onset of a stroke?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is caring for a client with an ischemic stroke who has apraxia. Which of the following deficits would the nurse expect the client to have?

Correct Answer is B

Explanation

A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

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The nurse is caring for a client who suffered a hemorrhagic stroke. In order to prevent increased intracranial pressure, the client should be placed in which position for the first 72 hours after the onset of a stroke?

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