A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Monitor the client's electrolyte levels.
Perform passive range of motion on each extremity.
Suction saliva from the client's mouth.
Record the client's intake and output.
The Correct Answer is C
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
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Correct Answer is A
Explanation
A. Managing cholesterol levels is crucial as high cholesterol can lead to plaque buildup in the arteries, increasing the risk of stroke.
B. Using oral contraceptives can actually increase the risk of stroke, especially in women who smoke or have other risk factors.
C. Maintaining a normal blood pressure is essential; elevated blood pressure can lead to increased risk of stroke, not good blood flow.
D. While moderate alcohol consumption may have some benefits, the general recommendation is to limit intake to reduce stroke risk; therefore, stating that up to 3 drinks a day is safe is misleading.
Correct Answer is B
Explanation
A. Using a thermometer to check the temperature of bath water is important for clients with PVD to prevent burns, indicating that this statement reflects understanding.
B. Wearing stockings with elastic tops is not recommended for clients with PVD as they can restrict blood flow and exacerbate symptoms. This indicates a need for further teaching.
C. The statement about not going barefoot is correct, as it helps prevent injury, which is crucial for clients with PVD.
D. Avoiding crossing legs is a proper action to promote circulation and prevent vascular complications, showing the client’s understanding of their condition.