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A nurse is assessing a client who has a hemorrhagic stroke. Which of the following findings should the nurse expect? (Select all that apply.)

A.

Sudden severe headache

B.

Facial drooping

C.

Slurred speech

D.

Nuchal rigidity

E.

Hemiparesis

Answer and Explanation

Correct Answer : A,D,E

Choice A reason:

This is a correct answer. Sudden severe headache is a common symptom of hemorrhagic stroke, which is caused by bleeding into the brain tissue or subarachnoid space. The headache may be described as "the worst headache of my life" or "thunderclap headache".

Choice B reason:

This is an incorrect answer. Facial drooping is a common symptom of ischemic stroke, which is caused by a blockage in a cerebral artery that reduces blood flow to the brain tissue. Facial drooping may affect one side of the face and cause asymmetry or difficulty smiling.

Choice C reason:

This is an incorrect answer. Slurred speech is another common symptom of ischemic stroke, which affects the areas of the brain responsible for language and communication. Slurred speech may also be accompanied by aphasia, which is difficulty understanding or expressing words.

Choice D reason:

This is a correct answer. Nuchal rigidity is a common symptom of subarachnoid hemorrhage, which is a type of hemorrhagic stroke that involves bleeding into the space between the brain and the meninges. Nuchal rigidity refers to stiffness or pain in the neck when flexing or extending it.

Choice E reason:

This is a correct answer. Hemiparesis is a common symptom of both ischemic and hemorrhagic stroke, which affect the motor areas of the brain and cause weakness or paralysis on one side of the body. Hemiparesis may affect the face, arm, leg, or trunk on the opposite side of the brain injury.


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Related Questions

Correct Answer is B

Explanation

Choice A reason:

This is an incorrect answer. Elevated troponin level is not a finding that indicates atrial fibrillation as the cause of ischemic stroke. Troponin is a cardiac enzyme that is released into the bloodstream when there is damage to the heart muscle, such as in myocardial infarction (MI) or heart failure. Troponin level may be elevated in some clients who have ischemic stroke due to concurrent cardiac conditions, but it does not indicate the source of embolism.

Choice B reason:

This is a correct answer. Elevated D-dimer level is a finding that indicates atrial fibrillation as the cause of ischemic stroke. D-dimer is a protein fragment that is produced when a blood clot is dissolved by fibrinolysis. D-dimer level may be elevated in clients who have ischemic stroke due to embolism from atrial fibrillation, which is an irregular and rapid heart rhythm that causes poor blood flow and clot formation in the atria.

Choice C reason:

This is an incorrect answer. Elevated C-reactive protein level is not a finding that indicates atrial fibrillation as the cause of ischemic stroke. C-reactive protein is an inflammatory marker that is produced by the liver in response to infection, inflammation, or tissue injury. C-reactive protein level may be elevated in clients who have ischemic stroke due to various causes, but it does not indicate the source of embolism.

Choice D reason:

This is an incorrect answer. Elevated INR is not a finding that indicates atrial fibrillation as the cause of ischemic stroke. INR is a measure of how long it takes for blood to clot, which reflects the effect of anticoagulant medications such as warfarin. INR may be elevated in clients who have ischemic stroke due to anticoagulant therapy, but it does not indicate the source of embolism.

Correct Answer is A

Explanation

Choice A reason:

This is a correct answer. Alteplase is a thrombolytic agent that dissolves blood clots and restores blood flow to the brain in clients who have an ischemic stroke. It should be administered within 3 to 4.5 hours of symptom onset and after ruling out hemorrhagic stroke.

Choice B reason:

This is an incorrect answer. Mannitol is an osmotic diuretic that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue and into the bloodstream. It is used for clients who have increased ICP due to cerebral edema, not ischemic stroke.

Choice C reason:

This is an incorrect answer. Nimodipine is a calcium channel blocker that prevents vasospasm and improves cerebral blood flow in clients who have a subarachnoid hemorrhage, which is a type of hemorrhagic stroke, not ischemic stroke.

Choice D reason:

This is an incorrect answer. Phenytoin is an anticonvulsant that prevents or treats seizures in clients who have a brain injury or tumor, not ischemic stroke.

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