A nurse is caring for a client who has suspected hemorrhagic stroke from a ruptured cerebral aneurysm. Which of the following manifestations would the nurse expect?

Gradual onset of several hours

Maintains consciousness

Neurologic deficits resolved in 1 hour

Complaints of the "worst headache of my life"

Answer and Explanation

The Correct Answer is D

A) Gradual onset of several hours:
Hemorrhagic strokes, particularly those caused by a ruptured cerebral aneurysm, typically present with sudden onset of symptoms rather than a gradual onset. The symptoms of a hemorrhagic stroke generally occur immediately or within minutes after the rupture.

B) Maintains consciousness:
While some patients may remain conscious initially after a cerebral aneurysm rupture, it is common for individuals with a ruptured cerebral aneurysm to experience loss of consciousness, or at least a decreased level of consciousness. The rupture causes an increase in intracranial pressure and often results in symptoms such as nausea, vomiting, and confusion, and may progress to coma or unresponsiveness.

C) Neurologic deficits resolved in 1 hour:
In the case of a hemorrhagic stroke, neurologic deficits do not typically resolve quickly, particularly after the rupture of a cerebral aneurysm. Neurological deficits associated with hemorrhagic strokes may include hemiparesis, aphasia, visual disturbances, and confusion. The concept of deficits resolving within 1 hour is more indicative of a transient ischemic attack (TIA).

D) Complaints of the "worst headache of my life":
One of the classic and most characteristic symptoms of a ruptured cerebral aneurysm (leading to hemorrhagic stroke) is a severe headache, often described by the patient as the "worst headache of my life." This sudden and intense headache occurs due to the bleeding into the subarachnoid space from the aneurysm rupture, which irritates the meninges and causes intense pain.

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Correct Answer is ["13.7"]

Explanation

Given:

Ordered dose of Furosemide: 1 mg/kg

Patient weight: 121 lbs

Concentration of Furosemide: 40 mg/10 mL (4 mg/mL)

Step 1: Convert patient weight from pounds to kilograms:

1 pound (lb) = 0.453592 kilograms (kg)

Patient weight in kg = 121 lbs x 0.453592 kg/lb = 54.877832 kg

Step 2: Calculate the total dose of Furosemide:

Total dose (mg) = Ordered dose (mg/kg) x Patient weight (kg)

Total dose (mg) = 1 mg/kg x 54.877832 kg

Total dose (mg) = 54.877832 mg

Step 3: Calculate the volume to be administered:

Volume (mL) = Total dose (mg) / Concentration (mg/mL)

Volume (mL) = 54.877832 mg / 4 mg/mL

Volume (mL) = 13.719458 mL

Step 4: Round to the nearest tenth:

Volume (mL) ≈ 13.7 mL

A. Determine when the patient last ate and call for spiritual advisor B. Assess vital signs and immediately notify the trauma surgeon C. Request an order for a chest x-ray and stop IV fluids D. Medicate the patient's pain and obtain consent for surgery

Correct Answer is B

Explanation

A) Determine when the patient last ate and call for spiritual advisor:
While it is important to gather a comprehensive history, including when the patient last ate, and to provide emotional support such as calling a spiritual advisor, these actions are not the priority in this situation. The immediate concern is the patient's physical condition and addressing the potential trauma to the chest and abdominal organs. Bowel sounds in the chest suggest a serious injury, such as a diaphragmatic rupture, which requires immediate surgical intervention.

B) Assess vital signs and immediately notify the trauma surgeon:
Hearing bowel sounds in the chest is a strong indication of a diaphragmatic injury, possibly a rupture, which can lead to the bowel being displaced into the chest cavity. This is a life-threatening emergency that can result in respiratory distress, impaired organ function, and infection. The nurse should assess vital signs to determine if the patient is stable or in shock and then immediately notify the trauma surgeon to facilitate urgent surgical intervention. Immediate surgical repair is necessary to prevent further complications such as respiratory compromise or sepsis.

C) Request an order for a chest x-ray and stop IV fluids:
A chest x-ray may be ordered later to confirm the presence of diaphragmatic injury or other chest trauma, but the priority action is to notify the trauma surgeon immediately. Stopping IV fluids is not appropriate in this situation; the patient likely needs continued fluid resuscitation, especially if they are in shock or have significant blood loss from their traumatic injuries.

D) Medicate the patient's pain and obtain consent for surgery:
Pain management is important for the patient’s comfort, but surgical intervention should not be delayed while obtaining consent. The trauma surgeon should be notified immediately, and surgery should be expedited without waiting for consent. In trauma cases, consent for life-saving procedures may be implied if the patient is unconscious or unable to provide consent due to the urgency of the situation.

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A nurse is caring for a client who has suspected hemorrhagic stroke from a ruptured cerebral aneurysm. Which of the following manifestations would the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 lbs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

Correct Answer is ["13.7"]

Explanation

The nurse is caring for a patient with multiple traumatic injuries following an occupational accident where the patient fell from a 30ft high ladder. Upon assessment, the-nurse hears bowel sounds in the chest. What should the nurse do next?

Correct Answer is B

Explanation

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