Nokea
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?
- A. Range-of-motion exercises to prevent contractures
- B. Encouraging independence with ADLs to promote recovery
- C. Early initiation of physical therapy
- D. Absolute bed rest in a quiet, nonstimulating environment
Correct Answer: D
Rationale: Absolute bed rest minimizes BP elevation, reducing bleeding risk in cerebral aneurysms. Activity-based interventions increase ICP and are contraindicated.
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A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patients safety during mobilization, the nurse should perform what action?
- A. Support the patients full body weight with a waist belt during ambulation.
- B. Have a colleague follow the patient closely with a wheelchair.
- C. Avoid mobilizing the patient in the early morning or late evening.
- D. Ensure that the patients family members do not participate in mobilization.
Correct Answer: B
Rationale: A wheelchair nearby ensures safety if the patient becomes fatigued or dizzy. Family participation is encouraged, and timing is not restricted.
What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke?
- A. Schedule passive range of motion every other day.
- B. Keep activity limited, as the patient may be over stimulated.
- C. Have the patient perform active range-of-motion (ROM) exercises once a day.
- D. Exercise the affected extremities passively four or five times a day.
Correct Answer: D
Rationale: Passive ROM four to five times daily prevents contractures and maintains mobility. Active ROM should be more frequent, and limited activity is not ideal.
A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurses best answer?
- A. We are trying to help her be as useful as possible.
- B. The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible.
- C. We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home.
- D. Rehabilitation means helping patients do exactly what they did before their stroke.
Correct Answer: B
Rationale: Rehabilitation emphasizes restoring self-care to maximize independence. Other responses oversimplify or misrepresent rehabilitation goals.
The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care?
- A. The patients hip joint should be maintained in a flexed position.
- B. The patient should be in a supine position unless ambulating.
- C. The patient should be placed in a prone position for 15 to 30 minutes several times a day.
- D. The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion.
Correct Answer: C
Rationale: Prone positioning with pelvic support promotes hip extension, preventing contractures. Flexed hips, supine-only positioning, and Trendelenberg are inappropriate.
The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?
- A. Providing frequent small meals rather than three larger meals
- B. Teaching the patient to perform deep breathing and coughing exercises
- C. Keeping a urinary catheter in situ for the full duration of recovery
- D. Limiting intake of insoluble fiber
Correct Answer: B
Rationale: Deep breathing and coughing prevent pneumonia, a common stroke complication. Frequent meals, prolonged catheters, and fiber limits are not indicated.