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 C

Explanation

Ventricular gallop is another name for the S3 sound, which is a low-pitched sound heard at the end of diastole, just after the S2 sound. It is caused by the rapid filling of the ventricles and the vibration of the ventricular walls.

Closure of the pulmonic valve is one of the components of the S2 sound, which is a high-pitched sound heard at the end of the systole, just before the S1 sound. It is caused by the closure of the semilunar valves (pulmonic and aortic).

Closure of the mitral valve is one of the components of the S1 sound, which is a high-pitched sound heard at the beginning of systole, just after the S2 sound. It is caused by the closure of the atrioventricular valves (mitral and tricuspid).

d. Atrial gallop is another name for the S4 sound, which is a low-pitched sound heard at the end of diastole, just before the S1 sound. It is caused by atrial contraction and increased resistance to ventricular filling.

A. Take this medication after each meal and at bedtime. B. Take one tablet every 15 min during an acute atack. C. Take this medication with 8 ounces of water. D. Take one tablet at the first indication of chest pain.

Correct Answer is D

Explanation

Taking one tablet at the first indication of chest pain is the correct way to use SL nitroglycerin tablets, as they are fast- acting and can relieve anginal symptoms within minutes. The client should place the tablet under the tongue and let it dissolve.

Taking this medication after each meal and at bedtime is not appropriate, as SL nitroglycerin tablets are not meant for routine or prophylactic use, but only for acute episodes of angina.

Taking one tablet every 15 min during an acute attack is not correct, as the client should not exceed three doses in 15 min. If the pain is not relieved after three doses, the client should seek emergency medical attention.

Taking this medication with 8 ounces of water is not necessary, as SL nitroglycerin tablets do not need to be swallowed or washed down with water. They should be dissolved under the tongue for optimal absorption.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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