Question

When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). The nurse will plan to do frequent assessments of the patient's

a. apical pulse.
b. bowel sounds.
c. breath sounds.
d. abdominal girth.

Answer 1

For a stroke patient with a history of GERD who is unconscious, the nurse should frequently assess breath sounds to detect potential aspiration and prevent pneumonia.

Step-by-step explanation:

When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, accompanied by a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's breath sounds. Patients with GERD are at risk for aspiration, especially when unconscious, which can lead to aspiration pneumonia. Monitoring breath sounds can help detect early signs of this complication.

While monitoring other aspects such as apical pulse, bowel sounds, and abdominal girth may be important in certain situations, the patient's history of GERD and the current unconscious state highlight the priority of respiratory assessments to prevent and detect potential complications related to aspiration.