What are some of the nursing interventions for the patient with a hemorrhagic stroke?
Encouraging lots of visitors
Out of bed with lots of walking in the halls
Nonstimulating, nonstressful environment; dim lighting, visitors are restricted
All of the above
The Correct Answer is C
Choice A: Encouraging lots of visitors is incorrect because it can increase the stimulation, stress, and noise level for the patient with a hemorrhagic stroke. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. This can cause increased intracranial pressure, brain damage, or death. The patient needs to rest and avoid any factors that can raise their blood pressure or worsen their condition.
Choice B: Out of bed with lots of walking in the halls is incorrect because it can also increase the risk of complications for the patient with a hemorrhagic stroke. The patient may have impaired mobility, balance, or coordination due to the brain injury. They may also have weakness, numbness, or paralysis on one side of the body. The patient needs to be assessed and assisted with their activity level and safety precautions.
Choice C: Nonstimulating, nonstressful environment; dim lighting, visitors are restricted is correct because it can help reduce the intracranial pressure and promote healing for the patient with a hemorrhagic stroke. The patient needs to have a quiet, calm, and comfortable environment that minimizes sensory input and emotional distress. The patient also needs to have limited and supervised visitors who are supportive and respectful of their needs.
Choice D: All of the above are incorrect because only choice c) is appropriate for the patient with a hemorrhagic stroke. Choices a) and b) are contraindicated and can harm or hinder the patient's recovery. The nurse should provide individualized and evidence-based care for the patient with a hemorrhagic stroke and follow the guidelines and protocols for stroke management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Nutrition supplements is not a direct intervention for maintaining skin integrity, but rather a general measure to support the patient's overall health and healing.
Choice B: Consulting speech therapy is not relevant for maintaining skin integrity, but rather for addressing the patient's communication and swallowing needs.
Choice C: Assessing the skin and frequent repositioning is a correct intervention for maintaining skin integrity, as it can prevent pressure ulcers or bedsores by reducing friction, shear, and moisture on the skin.
Choice D: Ambulating the patient as much as possible is not a specific intervention for maintaining skin integrity, but rather a general measure to promote the patient's mobility and circulation.
Correct Answer is B
Explanation
Choice A: Pressure ulcer is not the most serious complication of a patient with altered level of consciousness, but rather a common and preventable complication that can cause skin breakdown, infection, and pain.
Choice B: Aspiration is the most serious complication of a patient with altered level of consciousness, as it can cause pneumonia, respiratory failure, and death.
Choice C: Contractures is not the most serious complication of a patient with altered level of consciousness, but rather a potential and reversible complication that can cause muscle stiffness, joint deformity, and reduced mobility.
Choice D: Deep vein thrombosis is not the most serious complication of a patient with altered level of consciousness, but rather a possible and treatable complication that can cause blood clots, swelling, and pain in the legs.
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