Question

The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important?

a. Elevating the head of the bed at 30 degrees
b. Monitoring for seizure activity
c. Administering a stool softener d. Maintaining a patent airway

Answer 1

The most important intervention for a patient with a hemorrhagic stroke is maintaining a patent airway, as it is essential for oxygenation and preventing further brain injury. Other interventions are also important, but they follow in priority after airway management.

Step-by-step explanation:

The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The most important intervention is maintaining a patent airway. A hemorrhagic stroke occurs when a blood vessel within the brain ruptures, causing bleeding and potential brain damage due to the increased pressure and displacement of brain tissue. Timely management is critical in stroke care to limit damage and improve outcomes. While all options listed are important aspects of care, ensuring that the patient's airway is clear remains the top priority because it is essential for oxygenation of the brain and other organs.

Interventions such as elevating the head of the bed at 30 degrees can help reduce intracranial pressure and assist with venous drainage, while monitoring for seizure activity can be important due to the risk of seizures following a stroke. Administering a stool softener can prevent straining and thus reduce the risk of increasing intracranial pressure. However, these interventions come after securing the airway, which is the most immediate concern to prevent further brain injury and ensure the patient can breathe adequately.