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

The patient reports having a stiff neck.

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

The patient reports a severe and unrelenting headache.

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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Correct Answer is A

Explanation

A. BP 190/84, HR 50, and an irregular respiratory pattern is characteristic of Cushing's triad, a classic sign of increased intracranial pressure (ICP). Cushing's triad includes hypertension with a widened pulse pressure, bradycardia, and irregular or abnormal respirations. The elevated blood pressure occurs as a compensatory mechanism to maintain cerebral perfusion, while bradycardia and irregular respirations result from brainstem compression.

B. BP 190/84, HR 150, and an irregular respiratory pattern is incorrect because tachycardia (HR 150) is not part of Cushing's triad. Increased ICP typically causes bradycardia due to brainstem involvement.

C. BP 80/50, HR 50, and Kussmaul respirations: Kussmaul respirations are deep, rapid respirations commonly seen in metabolic acidosis, not typically associated with increased intracranial pressure.
D. BP 80/50, HR 150, and Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of deep breathing followed by apnea and are often seen in conditions affecting the brainstem, but they are not specific to increased intracranial pressure.

A. Apply an eye patch to the right eye. B. Teach the patient that the left visual deficit will resolve. C. Approach the patient from the right side. D. Place needed objects on the patient's left side.

Correct Answer is D

Explanation

A. Apply an eye patch to the right eye: Applying an eye patch to the right eye would further limit the patient's visual field, exacerbating the homonymous hemianopsia. This intervention is not appropriate for managing hemianopsia.

B. Teach the patient that the left visual deficit will resolve: Homonymous hemianopsia typically results from damage to the visual pathway in the brain and may not resolve completely. While visual rehabilitation techniques may help improve compensatory strategies, it is important to acknowledge and address the permanent nature of the deficit.

C. Approach the patient from the right side: Approaching the patient from the right side may startle them and increase the risk of falls or accidents due to the inability to perceive objects on their left side. The nurse should approach the patient from the unaffected side (the left side) to minimize the risk of injury.

D. Place needed objects on the patient's left side: Placing needed objects on the patient's left side helps compensate for the visual deficit by ensuring that essential items are within the patient's field of vision. This intervention promotes independence and safety for the patient with homonymous hemianopsia.

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

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