nursing care

Question 1

when should vitals be monitored for this patient?

Answer 1

Monitor vitals Q 1-2 hours!! Notify if BP is > 180/110. This can indicate an ischemic stroke is occuring.

Question 2

what is part of the neurovascular assessment?

Answer 2

A&O
GCS
Strength / pull / push / squeeze
Sensation
PERRLA
Temperature

Question 3

what includes seizure precautions?

Answer 3

Have suction available at bedside
Pad the bed railings
Do NOT put anything in the pts mouth
Turn pt on their side
Do not restrict the pt
Protect the pt’s head (you can lay their head in your lap)
Time the seizure, note an aura, and any side effects!

Question 4

how can the nurse communicate with a patient who has stroke?

Answer 4

1. Assess the ability to understand speech by asking the client to follow simple commands
2. Observe for consistently affirmative answers when the client actually does not comprehend what is being said
3. Assess accuracy of yes/no responses in relation to close-ended questions
4. Supply the client with a picture board
5. Speak slowly and clearly, use one-step commands.

Question 5

when should range of motion exercises be done?

Answer 5

Encourage passive ROM every 2 hours to the affected extremities and active ROM every 2 hours to the unaffected extremities. Teach the client how to use the unaffected side to exercise the affected side of the body.