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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. A client who has recently begun treatment with propranolol (Inderal) for the treatment of social phobia. Propranolol, a beta-blocker, does not have a significant risk for dependence or withdrawal symptoms. It is primarily used for physical symptoms of anxiety, such as tachycardia.

B. A woman who has been taking lorazepam (Ativan) for several months after witnessing a traumatic motor vehicle accident. Lorazepam is a benzodiazepine, which has a high potential for dependence and withdrawal, especially with long-term use. This client is the most at risk for these issues.

C. A man whose obsessive-compulsive disorder (OCD) is being treated long-term with paroxetine (Paxil). While discontinuation symptoms can occur with SSRIs like paroxetine, the risk of dependence is significantly lower than with benzodiazepines.

D. A client with generalized anxiety disorder who has responded well since beginning treatment with fluoxetine (Prozac) earlier in the year. Like paroxetine, fluoxetine is an SSRI, and while discontinuation symptoms may occur, the risk of dependence is low.

A. Alcohol tolerance B. Korsakoff's psychosis C. Delirium tremens D. Wernicke's encephalopathy

Correct Answer is C

Explanation

A. Alcohol tolerance: Alcohol tolerance refers to the decreased effect of alcohol with repeated use, not withdrawal symptoms.

B. Korsakoff's psychosis: Korsakoff's psychosis is a chronic condition related to thiamine deficiency and characterized by memory impairment and confabulation, not acute withdrawal symptoms.

C. Delirium tremens: Delirium tremens (DTs) is a severe form of alcohol withdrawal that can present with tremors, agitation, elevated blood pressure, tachycardia, and confusion. The client’s symptoms and recent history suggest DTs.

D. Wernicke's encephalopathy: Wernicke's encephalopathy typically presents with ataxia, confusion, and ophthalmoplegia rather than the acute withdrawal symptoms described.

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The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

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Naxlex Comprehensive Predictor Exams

Which of the following clients is most likely to be at risk for drug dependence and difficulties with withdrawal?

Correct Answer is B

Explanation

A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

Correct Answer is C

Explanation

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