A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Choice A reason: A history of neurologic deficits lasting less than 1 hr is not a typical manifestation of a hemorrhagic stroke. This could be a sign of a transient ischemic attack (TIA), which is a temporary blockage of blood flow to the brain that causes stroke like symptoms. A TIA is different from a hemorrhagic stroke, which is caused by bleeding in the brain due to a ruptured blood vessel.

Choice B reason: Manifestations preceded by a severe headache is a common manifestation of a hemorrhagic stroke. A ruptured cerebral aneurysm can cause sudden and intense pain in the head, often described as the worst headache of one's life. This is due to the increased pressure and irritation of the brain tissue and nerves by the blood leaking from the aneurysm.

Choice C reason: A gradual onset of several hours is not a usual manifestation of a hemorrhagic stroke. A hemorrhagic stroke is a medical emergency that requires immediate treatment, as the bleeding can cause rapid damage to the brain and increase the risk of death or disability. The symptoms of a hemorrhagic stroke usually develop suddenly and worsen quickly.

Choice D reason: Maintaining consciousness is not a likely manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause loss of consciousness, confusion, drowsiness, or coma due to the reduced blood flow and oxygen to the brain. The level of consciousness can also be affected by the location and extent of the bleeding, as well as the presence of complications such as hydrocephalus or vasospasm.

Choice A reason: Placing suction equipment at the client’s bedside is a necessary action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Acoustic neuroma is a noncancerous tumor that develops on the vestibulocochlear nerve, which is responsible for hearing and balance. It can also affect the adjacent cranial nerves, such as the glossopharyngeal (CN IX) and the vagus (CN X) nerves, which are involved in swallowing and gagging. A client with acoustic neuroma may have difficulty swallowing and clearing secretions, which can increase the risk of aspiration and respiratory infections. The nurse should have suction equipment ready to remove any excess saliva or mucus from the client’s mouth or throat.

Choice B reason: Avoiding the use of warm water to wash the client’s face is not a relevant action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. The temperature of the water does not affect the function of these nerves or the tumor. The nurse should use gentle and appropriate hygiene measures to clean the client’s face and prevent skin breakdown.

Choice C reason: Providing range of motion exercises to the client’s neck and shoulders is not a priority action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Range of motion exercises can help to maintain joint mobility and prevent stiffness, but they are not directly related to the cranial nerve impairment or the tumor. The nurse should consult with a physical therapist to determine the best exercise regimen for the client.

Choice D reason: Applying an eye patch to the client’s right eye is not a helpful action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. An eye patch is used to protect the eye from injury or infection, or to treat conditions such as strabismus or amblyopia. An eye patch does not affect the function of the cranial nerves IX and X or the tumor. The nurse should monitor the client’s eye movements and vision, as acoustic neuroma can also affect the facial (CN VII) and oculomotor (CN III) nerves, which are involved in blinking and eye movement.