Question

The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications?

a.Administer prescribed analgesics to promote pain relief.
b.Cluster nursing procedures together to avoid fatiguing the client.
c.Monitor neurologic and vital signs closely to identify early changes in status.
d.Position with the head of the bed flat to enhance cerebral perfusion.

Answer 1

The most critical intervention to prevent complications after a stroke is to monitor neurological and vital signs closely, which helps in managing treatments and identifying the need for any immediate actions.

Step-by-step explanation:

The nurse is caring for a client who had a stroke. To prevent complications during the first 72 hours, the nurse should implement which nursing intervention? The correct answer is c. Monitor neurologic and vital signs closely to identify early changes in status. This approach is critical to manage and adjust treatments in a timely fashion, which could include administering thrombolytic agents for certain types of stroke, repositioning the patient to prevent pressure ulcers, providing appropriate nutrition, and managing fluids and electrolytes. Keeping the head of the bed flat may not always be appropriate as individual patient conditions vary, and such positioning should be based on a physician's order and assessment of cerebral perfusion needs. Clustering nursing procedures may help avoid fatiguing the patient, but it does not have the same immediate impact on preventing complications as close monitoring of vitals and neurologic signs. While analgesics may be prescribed for pain relief, they are not a direct measure for preventing post-stroke complications.