HESI RN Exit Proctored Exam
Select All That Apply
A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.
Explanation & Rationale
A. Keeping the room brightly lit may contribute to confusion or agitation, especially in an acute stroke client. B. Monitoring speech for changes is critical in stroke patients, as sudden changes can indicate worsening neurological status. C. Changes in level of consciousness can indicate deterioration, and should be promptly reported to the nurse. D. Minimizing verbal interaction may not be helpful as it could isolate the client. It's more important to provide clear and calm communication. E. Avoiding sudden movements or sounds, such as dropping side rails or abruptly closing doors, can help reduce agitation and prevent injury.
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