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 D

Explanation

A. This option is primarily aimed at promoting lung expansion and preventing atelectasis (collapse of the lung). While it's an important post-operative intervention, it does not directly reduce the risk of embolic events related to venous thromboembolism.
B. Reporting significant pain (8/10) may indicate complications such as infection or improper healing, but it does not directly relate to reducing the risk of embolic events. While managing pain is important for recovery, simply reporting it does not contribute to preventing VTEs.
C. Assessing popliteal pulses is part of a thorough circulatory assessment, but it mainly focuses on blood flow to the lower extremities rather than preventing embolic events. It can help identify existing DVT but does not actively reduce the risk of embolism.
D. This statement is true and is the best choice for decreasing the risk of an embolic event. Early ambulation promotes venous return, improves circulation, and significantly lowers the risk of DVT and pulmonary embolism in post-operative patients. Encouraging patients to get out of bed and move around as soon as they are stable is a key nursing intervention in post-operative care.

A. Change in mental status B. Vital signs: T-98, P- 90, RR- 20, BP-142/88. C. Client states, "No discomfort or pain." D. Urine is cloudy with sediment

Correct Answer is A

Explanation

A. This is a significant finding that warrants immediate notification. Changes in mental status in elderly patients can indicate a variety of issues, including infection (such as a urinary tract infection), dehydration, or other acute illnesses. Given that elderly patients are at higher risk for delirium and other cognitive changes, this finding should be taken seriously.
B. These vital signs are largely within normal limits for an elderly patient. While the blood pressure is on the higher side, the heart rate and respiratory rate are within acceptable ranges. Therefore, this does not warrant immediate notification unless other symptoms are present.
C. This statement is reassuring and suggests that the client is not experiencing complications related to the indwelling catheter, such as infection or obstruction. It does not indicate any need for immediate notification of the provider.
D. Cloudy urine with sediment can be indicative of a urinary tract infection (UTI) or other complications related to the indwelling catheter. While this finding is concerning and may require further evaluation, it is not as urgent as a change in mental status. It should still be reported to the healthcare provider but may not necessitate immediate action.

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

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