The nurse is caring for a client who had a transurethral rection of the prostate 12 hours ago. The urine is clear and light red in color with a few small clots noted. Continuous bladder irrigation is running and the client is tolerating clear liquids without nausea or vomiting.  Pain is currently a 4 on the 0-10 scale. The nurse includes which intervention in this client’s plan of care?

The nurse receives an order to begin oral feedings for a client two days after a stroke. What is the first action the nurse should take before feeding the client?

The nurse develops the nursing diagnosis of “Unilateral Neglect related to sensory-perceptual deficits” for a client with a right hemisphere stroke. Which intervention should the nurse include in the client’s plan of care?

The home health nurse is caring for a client diagnosed with Alzheimer’s disease. The client’s family wants to keep them at home as long as possible and are opposed to nursing home placement, but report that the client has begun wandering more. One night they found the client out in the front yard at 2 a.m. The nurse develops the nursing diagnosis of “Wandering related to effects of memory loss as evidenced by the client wandering out of house at night.” What is the most appropriate nursing intervention in this situation?

The nurse recognizes that which type of stroke would be contraindicated to receive IV fibrinolytic therapy?

A public health nurse is providing teaching to a group of elderly clients at the senior citizen center on prevention of strokes. What measure(s) should the nurse include in the presentation? Select all that apply: 

A nurse is working in a long-term care facility and notices changes in a 76-year-old client.  The nurse suspects the client is having an acute stroke.  Which of the following are common manifestations of an acute stroke?(Select all that apply.)

A nurse is working in a long-term care facility and notices changes in a 76-year-old client.  The nurse suspects the client is having an acute stroke.  New data: The nurse, who noticed the sudden onset of symptoms (from the previous question) calls 911.  EMS arrives and transports the client to the emergency department (ED).  Based on the client’s symptoms of an acute stroke, which diagnostic test will be performed upon arrival to the Emergency Department?  

The nurse caring for an elderly resident in a long term care facility completes an assessment and finds the resident is not eating as well as usual and is confused. (The resident is usually alert and has a good appetite at meal time). The nurse further assesses the resident for signs and symptoms of?

A nurse is working in a long-term care facility and notices changes in a 76-year-old client.  The nurse suspects the client is having an acute stroke.  Which of the following are common manifestations of an acute stroke?(Select all that apply.)