A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
History of neurologic deficits lasting less than 1 hr
Maintains consciousness
Manifestations preceded by a severe headache
Gradual onset of several hours
The Correct Answer is C
- A hemorrhagic stroke is a type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. A common cause of hemorrhagic stroke is a cerebral aneurysm, which is a weak or bulging spot in an artery wall. When an aneurysm ruptures, it causes sudden and severe bleeding in the brain, which can damage brain cells and increase intracranial pressure. Symptoms of a hemorrhagic stroke include a sudden and severe headache, often described as "the worst headache of my life", followed by neurologic deficits, such as weakness, numbness, vision loss, speech problems, confusion, or loss of consciousness
- The other options are not correct because:
- History of neurologic deficits lasting less than 1 hr. This statement is incorrect because it describes a transient ischemic atack (TIA), which is a temporary interruption of blood flow to the brain that causes brief neurologic symptoms that resolve within 24 hours. A TIA is often a warning sign of an impending ischemic stroke, which is a type of stroke that occurs when a blood clot blocks an artery in the brain and reduces blood flow to the affected area.
- Maintains consciousness. This statement is incorrect because most clients with hemorrhagic stroke lose consciousness or have altered mental status due to the increased intracranial pressure and brain damage caused by the bleeding. The level of consciousness depends on the location and extent of the hemorrhage, but it usually deteriorates rapidly.
- Gradual onset of several hours. This statement is incorrect because hemorrhagic stroke usually has a sudden onset, unlike ischemic stroke, which may have a gradual onset over several hours or days. The onset of hemorrhagic stroke is often associated with physical exertion, emotional stress, or hypertension, which can increase the risk of aneurysm rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Moving objects away from the client is an important action to take during a seizure, as it can prevent injury and protect the client from harm.
"Place the client on his back." is not correct, as it can cause airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
"Restrain the client." is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
"Insert a padded tongue blade into the client's mouth." is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
Correct Answer is A
Explanation
The nurse should explain that cardiac enzyme studies measure the levels of certain enzymes, such as troponin, creatine kinase, and lactate dehydrogenase, that are released into the bloodstream when the heart muscle is damaged by an MI. These tests help determine the degree of damage to the heart tissues, as well as the timing and severity of the MI.
"These tests will enable the provider to determine the heart structure and mobility of the heart valves." is wrong because cardiac enzyme studies do not provide information about the heart structure and mobility of the heart valves. Other tests, such as echocardiography or cardiac catheterization, may be used for this purpose.
"Cardiac enzymes will identify the location of the MI." is wrong because cardiac enzyme studies do not indicate the specific location of the MI within the heart. Other tests, such as electrocardiography or coronary angiography, may be used for this purpose.
"Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." is wrong because cardiac enzyme studies do not directly assess the presence of pulmonary congestion, which is a complication of heart failure. Other signs and symptoms, such as dyspnea, crackles, and chest x-ray findings, may be used for this purpose.
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