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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B
Choice B reason: Intermittent claudication
Intermittent claudication is a characteristic symptom of PAD in the early stage, due to the reduced blood flow to the muscles during exercise. It is a cramping pain in the legs that occurs with walking and is relieved by rest.
Choice A reason: Dependent rubor is a sign of PAD in the advanced stage, due to the impaired vasodilation and reactive hyperemia. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
Choice C reason: Foot ulcers are a complication of PAD in the late stage, due to the poor wound healing and tissue necrosis. They are usually located on the toes, heels, or pressure points.
Choice D reason: Rest pain is another sign of PAD in the late stage, due to the severe ischemia and nerve damage. It is a persistent pain in the feet or toes that occurs at night and is not relieved by rest.
Correct Answer is B
Explanation
The P wave is the first wave on the ECG strip and represents the electrical activity of the atria. It reflects the depolarization of the atrial myocardium, which is the process of changing the electrical charge of the cardiac cells from negative to positive, triggering a contraction. The P wave precedes the QRS complex, which represents ventricular depolarization, and the T wave, which represents ventricular repolarization.
The other options are not correct because:
a. Slow repolarization of ventricular Purkinje fibers. This statement is incorrect because it describes the U wave, which is a small and sometimes invisible wave that follows the T wave on the ECG strip. It reflects the repolarization of the ventricular Purkinje fibers, which are specialized cardiac cells that conduct electrical impulses to the ventricles. The U wave is more prominent in conditions that cause hypokalemia, such as diuretic use or vomiting.
c. Early ventricular repolarization. This statement is incorrect because it describes the ST segment, which is the flat line between the QRS complex and the T wave on the ECG strip. It reflects the early phase of ventricular repolarization, which is the process of restoring the electrical charge of the cardiac cells to negative after a contraction. The ST segment can be elevated or depressed in conditions that cause myocardial ischemia or injury, such as angina or myocardial infarction.
d. Ventricular depolarization. This statement is incorrect because it describes the QRS complex, which is the largest and most visible wave on the ECG strip. It reflects the depolarization of the ventricular myocardium, which triggers a ventricular contraction. The QRS complex follows the P wave and precedes the T wave on the ECG strip.
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