Difficulty: Medium
Average Score: 68%
Simulated
A 70year old client diagnosed with a hemorrhagic stroke was admitted 1 day ago. His medical history includes hypertension, osteoarthritis, and type 2 diabetes. He has right sided paralysis, garbled speech, and a weak cough reflex. This morning he is restless. Vital signs are Blood Pressure 160/80, pulse 110, respirations 24, oxygen saturation 90% Which of the following Interventions will the nurse take to avoid complications? Select all that apply
Correct answer
A,B,C
Rationale
Applying oxygen addresses low saturation, monitoring blood pressure prevents further bleeding, and seizure precautions are necessary due to stroke-related seizure risk.