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Patient Data

The healthcare provider (HCP) tells the nurse that the client has a grade 2 subarachnoid hemorrhage.
Which finding(s) from the history and physical indicate that the client has a subarachnoid hemorrhage? Select all that apply.

Age

Medication history

Nuchal rigidity

Severe headache

Loss of appetite

Smoking history

Sluggish pupils

Answer and Explanation

Correct Answer : C,D,G

Rationale:
A. Age: While subarachnoid hemorrhage (SAH) can occur in adults of any age, age itself is not a specific indicator or diagnostic clue for SAH. It may influence risk factors but does not directly point to the hemorrhage.

B. Medication history: The client’s use of oral contraceptives and albuterol does not specifically indicate SAH. Medication history may affect overall health but is not diagnostic for acute hemorrhage.

C. Nuchal rigidity: Stiff neck is a classic sign of SAH due to meningeal irritation from blood in the subarachnoid space. Presence of nuchal rigidity strongly supports the diagnosis.

D. Severe headache: Often described as “the worst headache of my life,” a sudden, intense headache is a hallmark symptom of SAH and is one of the most important historical indicators.

E. Loss of appetite: Nausea and vomiting are associated with SAH, but loss of appetite is nonspecific and does not reliably indicate hemorrhage.

F. Smoking history: Smoking is a risk factor for vascular abnormalities, including aneurysms, but it is not an acute finding indicative of SAH at the time of presentation.

G. Sluggish pupils: Neurological changes, including dilated or sluggishly reactive pupils, indicate increased intracranial pressure or neurological compromise due to hemorrhage, supporting the presence of SAH.

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Correct Answer is C

Explanation

Rationale:
A. Hypotension: Acute pancreatitis can cause third-spacing and fluid shifts leading to hypotension, but this finding reflects intravascular volume depletion rather than a direct electrolyte disturbance. It is more closely related to hypovolemia and systemic inflammatory response.

B. Paralytic ileus and abdominal distention: Ileus commonly occurs in acute pancreatitis due to inflammation and peritoneal irritation. While electrolyte abnormalities can worsen ileus, this finding primarily reflects gastrointestinal motility impairment rather than a specific electrolyte imbalance.

C. Muscle twitching and digit numbness: Acute pancreatitis frequently causes hypocalcemia due to fat necrosis binding calcium. Neuromuscular irritability such as muscle twitching, perioral tingling, and numbness of digits are classic signs of low serum calcium. This finding directly indicates an electrolyte imbalance.

D. Hyperglycemia: Hyperglycemia results from impaired insulin secretion due to pancreatic inflammation. It reflects endocrine dysfunction rather than an electrolyte imbalance. Although common in pancreatitis, it does not indicate disturbed electrolyte levels.

A. Determine when symptoms began and if improved or worsened since onset. B. Administer aspirin to prevent further clot formation and platelet clumping. C. Verify prescribed laboratory tests include prothrombin time and platelet count. D. Keep the bed in the lowest position and initiate seizure and fall precautions.

Correct Answer is A

Explanation

Rationale:
A. Determine when symptoms began and if improved or worsened since onset: In suspected stroke, the timing of symptom onset is critical for determining eligibility for interventions such as thrombolytic therapy. Assessing whether symptoms are improving or worsening guides immediate treatment decisions and is the highest priority.

B. Administer aspirin to prevent further clot formation and platelet clumping: Administering aspirin may be contraindicated if the stroke is hemorrhagic. The type of stroke must first be determined via imaging before giving antiplatelet therapy.

C. Verify prescribed laboratory tests include prothrombin time and platelet count: Lab tests are important for baseline data and to guide future treatment, but they do not take priority over determining the timing and progression of neurological symptoms.

D. Keep the bed in the lowest position and initiate seizure and fall precautions: Safety measures are important to prevent injury but are secondary to establishing the timeline and nature of the neurological event, which drives urgent treatment.

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Patient Data The healthcare provider (HCP) tells the nurse that the client has a grade 2 subarachnoid hemorrhage. Which finding(s) from the history and physical indicate that the client has a subarachnoid hemorrhage? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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A client who sustained severe liver lacerations in a motorcycle collision is transported to the intensive care unit (ICU) following a segmental resection of the liver. One hour later, the nurse notes that the client is hemorrhaging from the surgical site. Which action should the nurse take?

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A client's telemetry monitor indicates the sudden onset of ventricular fibrillation (VF). Which assessment finding should the nurse anticipate?

Patient Data

The healthcare provider (HCP) tells the nurse that the client has a grade 2 subarachnoid hemorrhage.
Which finding(s) from the history and physical indicate that the client has a subarachnoid hemorrhage? Select all that apply.