During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow?

Cardiac dysrhythmias

Hypertension

53 and 54 heart sounds

Fluid overload

Answer and Explanation

The Correct Answer is B

A. Cardiac dysrhythmias:
While cardiac dysrhythmias can occur after a stroke, especially in the acute phase due to changes in autonomic regulation and increased sympathetic tone, they are not a direct compensatory response to increase cerebral blood flow. Dysrhythmias, such as atrial fibrillation, can occur as a result of stroke but are not a physiological response to attempts by the body to increase cerebral perfusion.

B. Hypertension:
Hypertension is a common cardiovascular response in the acute phase of a stroke. The body increases blood pressure to enhance cerebral perfusion and ensure that oxygen and nutrients are delivered to the brain, especially if there is impaired blood flow due to a clot or hemorrhage. This compensatory mechanism helps maintain adequate cerebral blood flow to areas at risk of ischemia. Therefore, hypertension is the most likely cardiovascular sign that the nurse would observe in response to a stroke, and it is a key sign that needs to be closely monitored and managed.

C. 53 and 54 heart sounds:
The presence of 53 and 54 heart sounds, also known as extra heart sounds, such as S3 and S4, may indicate heart failure, volume overload, or diastolic dysfunction. While these sounds can be associated with certain cardiovascular conditions, they are not a typical sign observed in the acute phase of a stroke as the body attempts to increase cerebral blood flow. These heart sounds are more related to heart conditions rather than stroke-induced changes in cerebral perfusion.

D. Fluid overload:
Fluid overload, although a potential complication in stroke patients (especially if they are given excessive IV fluids or have renal issues), is not a primary compensatory mechanism for increasing cerebral blood flow. Fluid overload could exacerbate other conditions, like increased intracranial pressure or pulmonary edema, but it does not directly serve the purpose of improving cerebral perfusion during a stroke. Hypertension, on the other hand, is a direct response to try to maintain cerebral blood flow.

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Correct Answer is A

Explanation

The client is showing signs of fluid overload due to heart failure exacerbation, including:

Progressive shortness of breath (fluid in the lungs)
Jugular venous distention (JVD) (increased central venous pressure)
Crackles in the lung bases (pulmonary congestion/edema)
Bounding pulse (increased circulating volume)

IV diuretics (e.g., Furosemide/Lasix) are the first-line treatment to rapidly reduce fluid overload by promoting diuresis and decreasing pulmonary congestion.

A. 5% Dextrose in water B. 10% Dextrose in water C. 0.9% Sodium Chloride D. 0.45% Sodium Chloride

Correct Answer is C

Explanation

A) "5% Dextrose in water (D5W)":
. D5W is an isotonic solution that, once metabolized by the body, becomes hypotonic because the glucose is rapidly utilized, leaving water. It is typically used to provide free water for hydration or for patients who need a small amount of calories or fluid, but it is not the best choice for this client. The client's low blood pressure and symptoms of dehydration (nausea, vomiting, dizziness, and weakness) suggest that normal saline (0.9% sodium chloride) is the more appropriate choice to help restore circulatory volume and improve blood pressure.

B) "10% Dextrose in water (D10W)":
. D10W is a hypertonic solution with a higher concentration of glucose, used in specific situations such as severe hypoglycemia or for patients requiring a high amount of glucose. It is not appropriate for this patient, whose primary issue seems to be volume depletion due to nausea and vomiting. The focus should be on replenishing circulatory volume and addressing the hypotension, which normal saline (0.9% sodium chloride) would do more effectively than D10W.

C) "0.9% Sodium Chloride":
. 0.9% Sodium Chloride (normal saline) is an isotonic solution and is the most appropriate choice for fluid resuscitation in a client with low blood pressure (hypotension) and signs of dehydration (nausea, vomiting, dizziness). This solution will help restore circulatory volume, correct hypovolemia, and improve blood pressure. It is commonly used for initial fluid resuscitation in clients who are hypotensive and experiencing fluid loss due to vomiting.

D) "0.45% Sodium Chloride (half-normal saline)":
. 0.45% Sodium Chloride is a hypotonic solution, which is more appropriate for treating patients who have conditions like hypernatremia or require gradual hydration. However, in this case, the patient is presenting with hypotension, dizziness, and weakness, which are signs of fluid depletion. A hypotonic solution would not be appropriate in this context, as it could potentially worsen the patient's hypotension or lead to further fluid shifts. The focus should be on using normal saline (0.9% sodium chloride) to help restore circulatory volume and improve the low blood pressure.

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During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow?

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Correct Answer is A

Explanation

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