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Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

A.

The patient reports having a stiff neck.

B.

The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

C.

The patient reports a severe and unrelenting headache.

D.

The patient's blood pressure (BP) is 90/50 mm Hg

Answer and Explanation

The Correct Answer is D

A.    The patient reports having a stiff neck: While a stiff neck may indicate meningeal irritation, which can be associated with a subarachnoid hemorrhage, it is not as immediately concerning as hypotension, which can indicate hypovolemic shock or complications such as vasospasm.

B.    The cerebrospinal fluid (CSF) report shows red blood cells (RBCs): The presence of red blood cells in the cerebrospinal fluid is expected in a subarachnoid hemorrhage and is an important diagnostic finding but may not require immediate intervention.

C.    The patient reports a severe and unrelenting headache: While a severe and unrelenting headache is a common symptom of subarachnoid hemorrhage, it is not as urgent as addressing hypotension, which can indicate hemodynamic instability and compromise perfusion to vital organs.

D.    The patient's blood pressure (BP) is 90/50 mm Hg: Hypotension in a patient with a subarachnoid hemorrhage can indicate hypovolemic shock, vasospasm, or other complications. It is important to communicate this finding promptly to the healthcare provider for further
evaluation and management.
 


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Related Questions

Correct Answer is B, E, A, D, C

Explanation

B. The first priority in a primary survey is to open and maintain the airway; in a trauma client, this is done with a jaw-thrust maneuver to protect the cervical spine. E. After the airway is established, the nurse should assess breathing and determine the effectiveness of ventilatory efforts. A. Once airway and breathing are stabilized, circulation is addressed by establishing IV access for fluid or blood administration. D. Disability is assessed next using tools such as the Glasgow Coma Scale to evaluate neurologic status. C. Exposure is the final step; the nurse removes clothing to perform a thorough assessment while preventing hypothermia.

Correct Answer is B

Explanation

A. Nuchal rigidity is a sign of meningitis but not specifically indicative of increased ICP.
B. Restlessness can be a sign of increased ICP due to reduced cerebral perfusion.
C. Photophobia is a common symptom of meningitis but does not directly indicate increased ICP.
D. Positive Kernig's sign is another indicator of meningitis but, like nuchal rigidity, it is not specific to increased ICP.

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