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 D

Explanation

A. Grab bars: Grab bars are useful for preventing falls in the bathroom but are unrelated to the client’s atrophy of olfactory organs, which affects the sense of smell.

B. Nonslip mats: Nonslip mats can help prevent falls but are not related to the client’s diminished sense of smell.

C. Baseboard heaters: Baseboard heaters are unrelated to olfactory atrophy and do not address the safety concerns associated with a reduced sense of smell.

D. A smoke detector: A smoke detector is essential for this client because the atrophy of olfactory organs means the client may not be able to detect the smell of smoke, increasing the risk of not noticing a fire.

A. "Are you frightened?" B. "You know I'm not following you." C. "You'll have to go into seclusion if you continue to threaten me." D. "I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch."

Correct Answer is D

Explanation

A. "Are you frightened?" This response is empathetic but may inadvertently reinforce the client's delusional thinking by focusing on the fear rather than addressing the delusion.

B. "You know I'm not following you." This response directly challenges the client's delusion, which could provoke defensiveness and escalate the situation.

C. "You'll have to go into seclusion if you continue to threaten me." This response is confrontational and may escalate the situation further by implying a threat, which could increase the client's fear and anger.

D. "I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch." This response acknowledges the client's feelings without reinforcing the delusion and provides a simple, non-threatening explanation for the nurse's actions. It helps de-escalate the situation by maintaining a calm, non-confrontational tone.

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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

An elderly client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?

Correct Answer is D

Explanation

As a nurse approaches the nurses' station, a client diagnosed with a delusional disorder raises his voice and says, "You're following me. What do you want?" To prevent escalating fear and anger, the nurse takes a nonthreatening posture and makes which response in a calm voice?

Correct Answer is D

Explanation

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