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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?

A.

History of neurologic deficits lasting less than 1 hr

B.

Maintains consciousness

C.

Manifestations preceded by a severe headache

D.

Gradual onset of several hours

Answer and Explanation

The Correct Answer is C

  1. 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
  2. The other options are not correct because:
  3. 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.
  4. 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.
  5. 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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Related Questions

Correct Answer is A

Explanation

The nurse should instruct the client to adjust the thermostat so that the environment is warm because cold temperatures can cause vasoconstriction and worsen the symptoms of PAD, such as pain, numbness, and poor wound healing. The client should also avoid exposure to cold weather and wear warm clothing.

  1. Apply a heating pad on a low setting to help relieve leg pain is wrong because it can cause burns, vasodilation, and increased blood flow to the legs, which can increase the risk of bleeding and edema in PAD.
  2. Wear antiembolic stockings during the day is wrong because they can impair arterial circulation and cause ischemia and tissue damage in PAD. Antiembolic stockings are used to prevent venous thromboembolism, not arterial disease.

Rest with the legs above heart level is wrong because it can decrease arterial blood flow to the legs and worsen ischemia and pain in PAD. The client should rest with the legs at or below heart level to promote arterial circulation.

Correct Answer is ["125"]

Explanation

To calculate the infusion rate, the nurse should use the following formula:

Infusion rate (mL/hr) = Volume (mL) / Time (hr)

Plugging in the given values, the nurse should get:

Infusion rate (mL/hr) = 250 mL / 2 hr

Infusion rate (mL/hr) = 125 mL/hr

The nurse should round the answer to the nearest whole number and use a leading zero if it applies. Therefore, the nurse should set the IV pump to deliver 125 mL/hr.

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