The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?
Generalized pain
Alteration in level of consciousness (LOC)
Tonic-clonic seizures
Shortness of breath
The Correct Answer is B
A. Generalized pain: Generalized pain is not a typical early sign of deterioration following a hemorrhagic stroke.
B. Alteration in level of consciousness (LOC): An alteration in LOC is often the earliest and most sensitive sign of neurological deterioration in clients who have had a hemorrhagic stroke. This can indicate increased intracranial pressure or further bleeding.
C. Tonic-clonic seizures: While seizures can occur after a stroke, they are not typically the earliest sign of deterioration. Changes in LOC usually precede seizure activity.
D. Shortness of breath: Shortness of breath may indicate respiratory issues but is not directly related to early neurological deterioration following a stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.
B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.
C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.
D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.
Correct Answer is C
Explanation
A. Bradycardia: Alcohol withdrawal typically presents with tachycardia (increased heart rate), not bradycardia (decreased heart rate).
B. Hypotension: Alcohol withdrawal is more likely to cause elevated blood pressure rather than hypotension.
C. Elevated temperature: Elevated temperature is a common sign of alcohol withdrawal, which can be accompanied by other symptoms like tremors and agitation.
D. Slurred speech: Slurred speech is more associated with alcohol intoxication rather than withdrawal.
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