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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client can obtain and maintain employment. While obtaining and maintaining employment can be a positive outcome, it does not specifically address the control of aggressive behaviors which are the focus here.
B. The client is free from aggressive behaviors. Being free from aggressive behaviors directly reflects successful treatment of aggressive symptoms in schizophrenia. This outcome specifically addresses the primary concern.
C. The client utilizes relaxation techniques. Utilizing relaxation techniques can be part of managing symptoms but does not directly measure the control of aggressive behaviours.
D. The client maintains healthy relationships with others. Maintaining healthy relationships is a positive outcome, but it is a broader goal and does not directly indicate control of aggressive behaviours.
Correct Answer is B
Explanation
A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.
B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.
C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.
D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.
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