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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Thrombotic stroke. A thrombotic stroke develops more gradually and is not typically associated with such sudden and severe symptoms.

B. Embolic stroke. An embolic stroke is often associated with a known embolic source, such as a clot from the heart, and can present more suddenly, but without all the symptoms seen here.

C. Hemorrhagic stroke: Hemorrhagic strokes often present with a sudden, severe headache, vomiting, seizure activity, and high blood pressure. A fever may also develop due to increased intracranial pressure.

D. Transient ischemic attack (TIA). TIAs are brief and resolve within minutes to hours and do not typically cause seizures.

A. Maintain hyperventilation to a PaCO2 of 15 to 20mm Hg. B. Routinely suction to prevent accumulation of respiratory secretions C. Encourage visitation to prevent feelings of isolation. D. Avoid positioning the client with neck and hip flexion.

Correct Answer is D

Explanation

A. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. Hyperventilation can reduce ICP by causing vasoconstriction of cerebral blood vessels; however, a PaCO2 as low as 15–20 mmHg may lead to excessive vasoconstriction, reducing cerebral blood flow and causing cerebral ischemia. A PaCO2 target closer to 30–35 mmHg is typically recommended, and even this is used cautiously.

B. Routinely suction to prevent accumulation of respiratory secretions. Suctioning can increase ICP due to stimulation of the cough reflex. It should be performed only as needed and in a way that minimizes stimulation, such as preoxygenation and limiting suction duration.

C. Encourage visitation to prevent feelings of isolation. While social support is important, minimizing environmental stimuli (including limiting visitation) is crucial for clients with increased ICP to prevent overstimulation and further increases in ICP.

D. Avoid positioning the client with neck and hip flexion. Maintaining proper alignment of the head and neck is essential to promote venous drainage and reduce intracranial pressure (ICP). Flexion of the neck or hips can impede venous outflow, exacerbate ICP, and compromise cerebral perfusion.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

The nurse is assessing a client with Paget's disease. Which finding would the nurse identify as being characteristic of this disease?

The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

A nurse is providing discharge education to a client who is going home with a cast on his leg. What education should the nurse emphasize in the teaching session?

The nurse obtains a health history from a patient with a prosthetic mitral value. Which question by the nurse would help to identify a risk factor for infectious endocarditis

The nurse is providing discharge instructions to a 76-year-old male client with chronic atrial fibrillation who has a CHA2DS2-VASC score of 2. Which medication would the nurse identify as most likely to be prescribed for the client?

The nurse is caring for a client who reports persistent, crushing chest pain. What additional signs or symptoms would make a nurse suspect that the client is experiencing a myocardial infarction?

The nurse is assessing a client with aortic stenosis. Which finding in the client's history would the nurse identify as the most common cause of this condition?

A nurse is caring for an alert client who reports heart palpitations, nausea, and dizziness. An electrocardiogram (EKG) confirms the client is experiencing vector tachycardia (VT). The nurse should anticipate which action?