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 pro-mote 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.
C
Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours.
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