The graduate nurse cares for several poststroke clients. Which of the following nursing interventions are appropriate? Select all that apply.

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Strokes cause different neurological deficits depending on the location of the affected area within the brain and the extent of injury. Cerebellar deficits affect balance and equilibrium; fall precautions are appropriate (Option A). Cranial nerves IX (glossopharyngeal) and X (vagus) control the gag and swallowing mechanisms, making swallow precautions necessary (Option C). Blindness in the same half of each visual field, homonymous hemianopsia, is suspected when clients ignore objects on one side. Initially, the nurse assists (eg, places utensil in unaffected visual field), but the client must learn to turn the head to scan the environment (Option D). homonymous hemianopsia (Option B) A stroke affecting cranial nerve VII, the facial nerve, can cause an asymmetrical smile or inability to raise one eyebrow. Increased light is unnecessary as vision is not affected. (Option E) Clients experiencing receptive aphasia, impaired comprehension of speech and writing, typically have injury to the Wernicke area of the brain, located in the left temporal lobe. The nurse would not speak louder as this does not aid comprehension. The nurse should speak clearly, ask "yes" or "no" questions, and use gestures and pictures to increase understanding. Wernicke area Educational objective: Strokes cause different neurological deficits depending on the location and extent of injury. Cerebellar deficits affect balance and require fall precautions, cranial nerve IX and X injuries can impair swallowing, and a client with homonymous hemianopsia will not see objects on the affected side.

The Graduate Nurse Cares for Several Poststroke Clients