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A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
- A. Gradual onset of headache
- B. Changes in consciousness
- C. Gradual onset of several hours
- D. History of neurologic deficits lasting less than 1 hr
Correct Answer: B
Rationale: The correct answer is B: Changes in consciousness. Following a hemorrhagic stroke from a ruptured cerebral aneurysm, changes in consciousness are expected due to the sudden bleeding into the brain causing increased intracranial pressure. This can lead to symptoms such as confusion, disorientation, stupor, or coma. Choice A is incorrect as a hemorrhagic stroke typically presents with a sudden and severe headache. Choice C is incorrect as the onset of symptoms is usually sudden. Choice D is incorrect as neurologic deficits from hemorrhagic strokes typically last longer than 1 hour.
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A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
- A. Insert a padded tongue blade into the client's mouth
- B. Restrain the client
- C. Move objects away from the client
- D. Place the client on his back
Correct Answer: C
Rationale: The correct answer is C: Move objects away from the client. This instruction is crucial to prevent injury during a seizure by creating a safe environment. Placing objects away from the client reduces the risk of them hitting or injuring themselves. It also allows for a clear space for the client's movements during the seizure.
Choice A is incorrect as inserting a padded tongue blade can cause injury and obstruct the client's airway. Choice B is incorrect as restraining the client can lead to further injury and is not recommended during a seizure. Choice D is incorrect as placing the client on their back can increase the risk of choking or aspiration if they vomit during the seizure.
The nurse is creating an education plan for a client who has a recent diagnosis of Multiple Sclerosis (MS). Which of the following interventions should the nurse include in the client's plan?
- A. Recommend the client engage in high-impact, vigorous exercises to improve muscle strength
- B. Teach the client stress management techniques such as deep breathing and meditation
- C. Advise the client to avoid social interactions to minimize stress
- D. Encourage the client to void every hour
Correct Answer: B
Rationale: The correct answer is B: Teach the client stress management techniques such as deep breathing and meditation. This intervention is appropriate for a client with MS as stress can exacerbate symptoms. Deep breathing and meditation are proven techniques to reduce stress levels, promote relaxation, and improve overall well-being. By incorporating stress management techniques into the education plan, the nurse can help the client cope better with the emotional and physical challenges of living with MS.
Choice A is incorrect because high-impact, vigorous exercises can actually worsen symptoms and fatigue in clients with MS. Choice C is incorrect as social interactions can provide emotional support and should not be avoided. Choice D is incorrect as there is no specific indication for encouraging the client to void every hour in the context of MS.
The nurse is working on discharge planning for a 25-year-old hospitalized client diagnosed with Multiple Sclerosis (MS). The client has significant bilateral lower extremities muscle weakness. Which of the following facilities should the nurse expect this client to be discharged to?
- A. Home care services
- B. Sub-acute care facility
- C. Rehabilitation facility
- D. Skilled nursing facility
Correct Answer: C
Rationale: The correct answer is C: Rehabilitation facility. This is the appropriate choice because a rehabilitation facility specializes in providing intensive therapy and support for clients with muscle weakness, such as the client with MS in this case. The client needs structured rehabilitation services to improve muscle strength and function. Home care services (A) may not provide sufficient support and resources for the client's needs. Sub-acute care facility (B) is more suitable for clients who require ongoing medical care or monitoring. Skilled nursing facility (D) is typically for clients who need long-term nursing care rather than intensive rehabilitation.
A nurse is caring for a client receiving rehabilitation for paralysis following a spinal cord injury and diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
- A. Limited fluid intake to prevent incontinence
- B. Administration of antispasmodic medication
- C. Kegel exercises to strengthen the pelvic floor
- D. Regular perineal care to prevent skin breakdown
Correct Answer: D
Rationale: The correct answer is D: Regular perineal care to prevent skin breakdown. This is the highest priority intervention because reflex incontinence can lead to constant urine leakage, increasing the risk of skin breakdown. Regular perineal care helps maintain skin integrity, preventing complications like pressure ulcers. Limited fluid intake (A) is not appropriate as it can lead to dehydration. Antispasmodic medication (B) may help manage muscle spasms but does not address skin breakdown. Kegel exercises (C) are beneficial for stress incontinence, not reflex incontinence.
A nurse is caring for a client who has experienced a hemorrhagic stroke. Which intervention should the nurse prioritize when providing care to the client?
- A. Assisting the client with active range of motion exercises
- B. Maintaining strict bed rest to minimize cerebral blood flow
- C. Monitoring vital signs and neurological status frequently
- D. Administering anticoagulant medications as prescribed
Correct Answer: C
Rationale: The correct answer is C: Monitoring vital signs and neurological status frequently. This is crucial in caring for a client who has experienced a hemorrhagic stroke as it allows for early detection of any changes in condition such as increased intracranial pressure or neurological deterioration. Vital signs provide important information about the client's overall condition, while neurological status assessments help in evaluating brain function and detecting any signs of worsening stroke symptoms. This intervention is essential for prompt intervention and preventing further complications.
Incorrect answers:
A: Assisting the client with active range of motion exercises - This is not a priority in the acute phase of a hemorrhagic stroke as it can potentially worsen the condition.
B: Maintaining strict bed rest to minimize cerebral blood flow - While bed rest is important, strict bed rest may not be necessary, and minimizing cerebral blood flow is not the primary goal.
D: Administering anticoagulant medications as prescribed - Anticoagulants are contraindicated in hemorrhagic strokes as