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?

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.

A) "The procedure can help determine whether your stroke was caused by a clot or by bleeding": This statement is incorrect. An electroencephalogram (EEG) is a diagnostic test used to evaluate the electrical activity of the brain, not to assess stroke-related causes. To determine whether a stroke was caused by a clot or bleeding, imaging studies like a CT scan or MRI are typically used, not an EEG.

B) "The procedure can help identify which part of the brain seizure activity is coming from": This is the correct response. An EEG records electrical activity in the brain and is primarily used to diagnose and monitor conditions such as seizures, epilepsy, and sleep disorders. It can help pinpoint the area of the brain where abnormal electrical activity, such as that seen in seizures, is originating. This makes it an invaluable tool for understanding seizure disorders.

C) "The procedure helps evaluate nerve function to your extremities": This statement is inaccurate. An EEG does not assess nerve function to the extremities. Tests like nerve conduction studies or electromyography (EMG) are used to evaluate peripheral nerve function, whereas an EEG specifically measures electrical activity in the brain.

D) "The procedure shows images of your heart’s electrical activity": This statement is incorrect. An EEG measures brain electrical activity, not the heart's. To assess the heart's electrical activity, an electrocardiogram (ECG or EKG) is used. Therefore, an EEG and an ECG serve very different purposes.