Patient Data
The nurse considers the pathophysiological similarities and differences between hemorrhagic and ischemic stroke. Click to indicate which manifestation is typically indicative of hemorrhagic, ischemic, or both types of strokes. Each column must have at least one response option selected.

Decreased level of consciousness (LOC)

Unilateral symptoms

Sudden symptom onset

Alert at cognitive baseline

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Rationale for correct choices

• Decreased level of consciousness (LOC): Hemorrhagic strokes involve bleeding into the brain tissue or subarachnoid space, which increases intracranial pressure and can rapidly impair cerebral perfusion. This often results in decreased LOC or sudden deterioration in alertness. Ischemic strokes may present with normal LOC, particularly in smaller or non-dominant hemisphere infarcts.

• Unilateral symptoms: Both stroke types typically cause deficits on one side of the body corresponding to the affected cerebral hemisphere. Manifestations may include hemiparesis, facial droop, and unilateral sensory loss. The laterality of symptoms is a hallmark in both ischemic and hemorrhagic strokes.

• Sudden symptom onset: Hemorrhagic strokes usually present with abrupt, severe onset, often described as “worst headache of my life” or sudden neurological deficits. While ischemic strokes can also develop suddenly, hemorrhagic strokes generally have a more dramatic and immediate presentation.

• Alert at cognitive baseline: Many ischemic strokes, especially small-vessel infarcts, may occur without immediately affecting consciousness. Patients often remain alert and oriented at baseline, although unilateral neurological deficits are present. This contrasts with hemorrhagic strokes, where LOC is frequently compromised.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Support the client in an upright position until the belt is removed: Trying to keep a falling client upright increases the risk of both client and nurse injury. It is unsafe and does not control the fall effectively.

B. Ease the client to the floor while holding the gait belt securely: Lowering the client safely to the floor using the gait belt protects the client from injury and minimizes risk to the nurse. This is the standard safe procedure for fall prevention during ambulation.

C. Advise the client to grab hold of the gait belt for added support: During a sudden fall, the client may not have the strength, coordination, or reaction time to grab the belt effectively, so this is not a safe or reliable action.

D. Use the gait belt to slowly guide the client back to the room: Attempting to redirect or guide the client while they are falling does not prevent injury and may worsen the fall. Safe lowering to the floor is the priority.

A. Blood pressure. B. Temperature. C. Respiratory rate. D. Pulse rate.

Correct Answer is C

Explanation

Rationale:
A. Blood pressure: While important for assessing perfusion and potential causes of altered consciousness, blood pressure changes may not immediately indicate a life-threatening compromise in oxygenation. It should be assessed after airway and breathing.

B. Temperature: Fever or hypothermia can affect mental status, but temperature changes develop more slowly and do not immediately threaten airway or oxygenation. It is not the first priority in acute changes in consciousness.

C. Respiratory rate: Altered level of consciousness often results from or leads to respiratory compromise. Assessing the respiratory rate first allows the nurse to detect hypoventilation, apnea, or other airway problems that require immediate intervention to prevent hypoxia and further deterioration.

D. Pulse rate: Heart rate provides information about circulatory status, but bradycardia or tachycardia alone does not directly address immediate airway or oxygenation concerns. It is important but secondary to assessing respiration in an acutely altered client.

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Naxlex Comprehensive Predictor Exams

After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

Correct Answer is C

Explanation

The nurse prepares to educate the client and spouse. Click to select the 3 items that the nurse should include in the plan of care after administration of tissue plasminogen activator (tPA).

Patient Data For each nursing intervention, click to indicate whether the action is appropriate or not appropriate for this client. Each row must have only one response option selected.

The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed?

Patient Data For each assessment finding click to indicate whether findings from this client's assessment are associated with cerebral vascular accident, liver disorder, or thrombocytopenia. Each column must have at least one response option selected.

Patient Data The nurse considers the client's symptoms. Which assessment finding(s) support the suspected diagnosis of acute stroke? Select all that apply.

A client reports to the nurse about feeling upset because no family or friends have visited in two days. The client then begins to shout and toss small objects toward the nurse. Which defense mechanism should the nurse recognize the client is displaying?