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 C

Explanation

A. Emaciation: Emaciation refers to extreme weight loss and muscle wasting due to severe malnutrition, not just loss of appetite.

B. Cachexia: Cachexia is a complex syndrome associated with chronic illness, characterized by severe weight loss, muscle atrophy, and fatigue. While it may include loss of appetite, it’s not the best term for simple loss of appetite.

C. Anorexia: Anorexia is the correct medical term for loss of appetite. It can be related to various conditions, including prolonged illness.

D. Nausea: Nausea is a sensation of discomfort in the stomach with an urge to vomit, not loss of appetite.

A. Wear sterile gloves. B. Place incontinence pads in the regular trash container. C. Wear personal protective equipment when handling blood, body fluids, and feces. D. Provide a urinal or bedpan to decrease the likelihood of soiling linens.

Correct Answer is C

Explanation

A. Wear sterile gloves. Sterile gloves are typically required for invasive procedures, not general care after chemotherapy. The key concern here is exposure to chemotherapy agents in bodily fluids.

B. Place incontinence pads in the regular trash container. Incontinence pads and other items contaminated with bodily fluids should be disposed of in a hazardous waste container, not regular trash, to prevent exposure to chemotherapy agents.

C. Wear personal protective equipment when handling blood, body fluids, and feces. Chemotherapy agents can be excreted in bodily fluids, so wearing PPE is essential to protect the healthcare worker from exposure.

D. Provide a urinal or bedpan to decrease the likelihood of soiling linens. While providing a urinal or bedpan may be practical, it does not address the key concern of handling potentially contaminated bodily fluids safely.

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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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