Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

A right sided calcaneal spur

A blood pressure of 222/112 mmHg

Glycosylated hemoglobin of 5.9%

Recent endoscopy

Answer and Explanation

The Correct Answer is B

A.   A calcaneal spur, or heel spur, is a bony growth on the heel bone. This condition is primarily related to foot pain and does not have a direct link to the risk of stroke. It is not relevant in assessing stroke risk.
B.   This elevated blood pressure reading indicates hypertension, which is a significant risk factor for both ischemic and hemorrhagic strokes. Chronic high blood pressure can lead to damage of the blood vessels, making them more susceptible to rupture, thus increasing the risk of a hemorrhagic stroke.
C.   A glycosylated hemoglobin (HbA1c) level of 5.9% indicates well-managed diabetes, typically within the normal range for most individuals. While uncontrolled diabetes is a risk factor for vascular disease, this level suggests adequate control and does not specifically indicate an increased risk for a hemorrhagic stroke.
D.   A recent endoscopy itself does not indicate a direct risk for a hemorrhagic stroke. However, if the endoscopy was performed due to gastrointestinal bleeding or if it resulted in complications, there could be indirect implications, but this option alone does not signify an increased risk for hemorrhagic stroke.

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Correct Answer is C

Explanation

A. This is not an appropriate action as it can increase pressure on the bladder and worsen the spasms.
B. While warming the irrigation solution can help to prevent discomfort, it is not the most effective way to address the bladder spasms.
C. Belladonna and opium suppositories are commonly used to relieve bladder spasms. They work by relaxing the muscles in the bladder and reducing pain. In a client who has undergone TURBT and is experiencing continuous bladder irrigation, these suppositories can be an effective way to manage discomfort.
D. Meperidine is a narcotic pain reliever that can be used to manage pain after surgery. However, it is not specifically indicated for bladder spasms and may not be the most appropriate medication in this case.

A. Avoiding arm exercise in the immediate post-op period B. Instruct the client to sleep in the left lateral side lying position C. Placing cool compresses on the affected arm D. Elevating the affected arm on a pillow above the level of the heart

Correct Answer is D

Explanation

A. This statement is not advisable. While it is essential to avoid strenuous activity initially, gentle arm exercises and range-of-motion activities are generally encouraged as soon as possible to promote circulation and help prevent lymphedema. Immobilization can actually increase the risk of lymphedema.
B. This intervention is not recommended for preventing lymphedema. Sleeping on the side of the surgery (in this case, the left side) can put pressure on the affected arm and may not promote proper lymphatic drainage. Clients are often advised to sleep on their back or to position themselves in a way that does not compress the affected arm.
C. This intervention can provide temporary relief if there is swelling or discomfort, but it does not effectively prevent lymphedema. While cool compresses might help reduce inflammation, they are not a primary measure for lymphedema prevention.
D. This is the most effective intervention for preventing lymphedema. Elevating the affected arm helps facilitate lymphatic drainage and reduces the risk of fluid accumulation. Keeping the arm elevated above heart level encourages proper circulation and helps manage swelling.

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Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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