A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

The patient's blood pressure (BP) is 144/90 mm Hg.

The patient takes a diuretic because of a history of hypertension.

The patient has atrial fibrillation and takes warfarin (Coumadin).

The patient's speech is difficult to understand.

Answer and Explanation

The Correct Answer is C

A. The patient's blood pressure (BP) is 144/90 mm Hg: While elevated blood pressure may contribute to the risk of intracerebral hemorrhage, the patient's current BP is not excessively high and may not be the most critical factor in this situation compared to other factors such as anticoagulant use.

B. The patient takes a diuretic because of a history of hypertension: While the patient's history of hypertension and diuretic use are relevant to their overall health status, they may not be the most immediate concern in the context of intracerebral hemorrhage.

C. The patient has atrial fibrillation and takes warfarin (Coumadin): This information is crucial as it indicates that the patient is anticoagulated, which can significantly impact the severity and management of intracerebral hemorrhage. Anticoagulant use increases the risk of bleeding and can worsen outcomes in cases of intracranial hemorrhage.

D. The patient's speech is difficult to understand: While difficulty with speech may indicate neurological impairment, it is not as immediately concerning as the patient's anticoagulant use, which increases the risk of bleeding complications and may require specific interventions such as reversal agents.

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Correct Answer is A

Explanation

A. BP 190/84, HR 50, and an irregular respiratory pattern is characteristic of Cushing's triad, a classic sign of increased intracranial pressure (ICP). Cushing's triad includes hypertension with a widened pulse pressure, bradycardia, and irregular or abnormal respirations. The elevated blood pressure occurs as a compensatory mechanism to maintain cerebral perfusion, while bradycardia and irregular respirations result from brainstem compression.

B. BP 190/84, HR 150, and an irregular respiratory pattern is incorrect because tachycardia (HR 150) is not part of Cushing's triad. Increased ICP typically causes bradycardia due to brainstem involvement.

C. BP 80/50, HR 50, and Kussmaul respirations: Kussmaul respirations are deep, rapid respirations commonly seen in metabolic acidosis, not typically associated with increased intracranial pressure.
D. BP 80/50, HR 150, and Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of deep breathing followed by apnea and are often seen in conditions affecting the brainstem, but they are not specific to increased intracranial pressure.

A. Confusion B. Aphasia C. Pain D. Falls

Correct Answer is D

Explanation

A. Confusion: While confusion may occur in some neurological conditions, it is not directly associated with a positive Romberg test result.

B. Aphasia: Aphasia refers to difficulty with language and communication and is typically associated with brain injury or stroke, not with a positive Romberg test result.

C. Pain: Pain is not directly assessed by the Romberg test. However, a positive Romberg test result may indicate sensory ataxia, which can contribute to difficulty with proprioception and coordination, potentially leading to increased risk of injury and pain.

D. Falls: A positive Romberg test result indicates impaired proprioception and balance,
increasing the risk of falls, especially in older adults or individuals with neurological conditions. This is the expected problem associated with a positive Romberg test result.

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A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

Correct Answer is A

Explanation

Which problem should the nurse expect for a patient who has a positive Romberg test result?

Correct Answer is D

Explanation

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