A family member of a patient diagnosed with a hemorrhagic stroke asks if the patient can receive anticoagulant therapy to improve their outcome. The nurse explains that anticoagulant therapy for the patient

may be necessary to prevent pulmonary thrombosis.

is contraindicated because it will cause additional bleeding.

is inadvisable because it may mask signs and symptoms of neurologic changes in the brain.

will be started if necessary to enhance cerebral circulation.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect. Anticoagulant therapy may be necessary to prevent pulmonary thrombosis in patients with ischemic stroke, which is caused by a blood clot blocking a blood vessel in the brain. However, in patients with hemorrhagic stroke, which is caused by a ruptured blood vessel in the brain, anticoagulant therapy can worsen the bleeding and increase the risk of complications.

Choice B reason: This is correct. Anticoagulant therapy is contraindicated because it will cause additional bleeding in patients with hemorrhagic stroke. Anticoagulants are drugs that prevent blood from clotting or dissolve existing clots. They can increase the size of the hematoma and the pressure on the brain tissue, leading to more damage and disability.

Choice C reason: This is incorrect. Anticoagulant therapy is not inadvisable because it may mask signs and symptoms of neurologic changes in the brain. Anticoagulants do not affect the neurological assessment or the diagnosis of stroke. They can, however, interfere with the treatment and recovery of hemorrhagic stroke.

Choice D reason: This is incorrect. Anticoagulant therapy will not be started if necessary to enhance cerebral circulation in patients with hemorrhagic stroke. Anticoagulants do not improve the blood flow to the brain, but rather prevent or dissolve clots that may obstruct it. In patients with hemorrhagic stroke, the pro

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Correct Answer is A

Explanation

Choice A reason:Swaying during a Romberg test indicates a positive result, suggesting proprioceptive deficits or sensory ataxia.

Choice B reason: Unequal pupil response to light relates to cranial nerve function, not balance assessed by the Romberg test.

Choice C reason: This is incorrect. Patient taking two attempts to touch their nose while their eyes are closed is a mild impairment of coordination, which may be due to neurologic changes or other factors such as fatigue or medication. This is not a significant finding that requires immediate attention.

Choice D reason: This is incorrect. Patient complaining of mild dizziness is a common symptom of neurologic changes or vestibular dysfunction. It is not a serious finding that requires immediate attention. The nurse should monitor the patient and provide comfort measures.

A. Maintain a flat lying position for 14 hours following the procedure. B. Muscular discomfort is expected after being in a curled position for a period of time. C. Resume oral intake immediately after the procedure. D. Mild pain is expected at the needle insertion site.

Correct Answer is A

Explanation

Choice A reason: Maintaining a flat lying position for 14 hours following the procedure is the highest priority teaching point for the patient who had a lumbar puncture. It helps to prevent cerebrospinal fluid leakage and post-lumbar puncture headache, which can be severe and debilitating.

Choice B reason: Muscular discomfort is expected after being in a curled position for a period of time, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, massage, or heat therapy.

Choice C reason: Resuming oral intake immediately after the procedure is not a priority teaching point for the patient who had a lumbar puncture. It is not contraindicated, but it is not essential either. The patient should drink plenty of fluids to replenish the cerebrospinal fluid and prevent dehydration.

Choice D reason: Mild pain is expected at the needle insertion site, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, ice packs, or dressing.

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A family member of a patient diagnosed with a hemorrhagic stroke asks if the patient can receive anticoagulant therapy to improve their outcome. The nurse explains that anticoagulant therapy for the patient

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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