A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? Select all that apply.

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11ecbb05_ca3b_7ed8_b433_a5ee2d27d982_MD0009_00 A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP) (Option C). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option D). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option E). Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should: Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors Administer stool softeners to reduce strain during bowel movements (Option A) Reduce exertion, maintain strict bed rest, assist with activities of daily living Maintain head in midline position to improve jugular venous return to the heart (Option B) Enoxaparin is an anticoagulant used to prevent venous thromboembolism (VTE). Anticoagulants are contraindicated in clients with hemorrhagic stroke; the nurse should question any prescriptions that increase risk for bleeding. A client with hemorrhagic stroke should instead receive nonpharmacologic interventions (eg, compression stockings) to prevent VTE. Educational objective: A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding. The nurse should perform frequent neurological assessments, keep the client NPO, maintain seizure precautions and strict bed rest, and limit any activity that may increase bleeding (eg, anticoagulant administration) or intracranial pressure (eg, stimulation, straining during bowel movements).

A Hospitalized Client Develops Acute Hemorrhagic Stroke and Is Transferred