A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

History of neurologic deficits lasting less than 1 hr

Maintains consciousness

Manifestations preceded by a severe headache

Gradual onset of several hours

Answer and Explanation

The Correct Answer is C

A hemorrhagic stroke is a type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. A common cause of hemorrhagic stroke is a cerebral aneurysm, which is a weak or bulging spot in an artery wall. When an aneurysm ruptures, it causes sudden and severe bleeding in the brain, which can damage brain cells and increase intracranial pressure. Symptoms of a hemorrhagic stroke include a sudden and severe headache, often described as "the worst headache of my life", followed by neurologic deficits, such as weakness, numbness, vision loss, speech problems, confusion, or loss of consciousness
The other options are not correct because:
History of neurologic deficits lasting less than 1 hr. This statement is incorrect because it describes a transient ischemic atack (TIA), which is a temporary interruption of blood ﬂow to the brain that causes brief neurologic symptoms that resolve within 24 hours. A TIA is often a warning sign of an impending ischemic stroke, which is a type of stroke that occurs when a blood clot blocks an artery in the brain and reduces blood ﬂow to the aﬀected area.
Maintains consciousness. This statement is incorrect because most clients with hemorrhagic stroke lose consciousness or have altered mental status due to the increased intracranial pressure and brain damage caused by the bleeding. The level of consciousness depends on the location and extent of the hemorrhage, but it usually deteriorates rapidly.
Gradual onset of several hours. This statement is incorrect because hemorrhagic stroke usually has a sudden onset, unlike ischemic stroke, which may have a gradual onset over several hours or days. The onset of hemorrhagic stroke is often associated with physical exertion, emotional stress, or hypertension, which can increase the risk of aneurysm rupture.

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Correct Answer is A

Explanation

The nurse should explain that cardiac enzyme studies measure the levels of certain enzymes, such as troponin, creatine kinase, and lactate dehydrogenase, that are released into the bloodstream when the heart muscle is damaged by an MI. These tests help determine the degree of damage to the heart tissues, as well as the timing and severity of the MI.

"These tests will enable the provider to determine the heart structure and mobility of the heart valves." is wrong because cardiac enzyme studies do not provide information about the heart structure and mobility of the heart valves. Other tests, such as echocardiography or cardiac catheterization, may be used for this purpose.

"Cardiac enzymes will identify the location of the MI." is wrong because cardiac enzyme studies do not indicate the specific location of the MI within the heart. Other tests, such as electrocardiography or coronary angiography, may be used for this purpose.

"Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." is wrong because cardiac enzyme studies do not directly assess the presence of pulmonary congestion, which is a complication of heart failure. Other signs and symptoms, such as dyspnea, crackles, and chest x-ray findings, may be used for this purpose.

A. Place a moist heating pad under the client's feet. B. Increase the client's oral ﬂuid intake. C. Obtain a pair of slipper-socks for the client. D. Rub the client's feet briskly for several minutes.

Correct Answer is C

Explanation

Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood ﬂow and comfort.

Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased ﬂuid loss, which can worsen the condition.

Increasing the client's oral ﬂuid intake is not relevant, as it does not aﬀect the temperature or circulation of the feet.

Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inﬂammation, or ulceration to the fragile skin and tissues of the feet.

Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood ﬂow and comfort.

Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased ﬂuid loss, which can worsen the condition.

Increasing the client's oral ﬂuid intake is not relevant, as it does not aﬀect the temperature or circulation of the feet.

Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inﬂammation, or ulceration to the fragile skin and tissues of the feet.

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A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

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