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

Gradual onset of several hours

Maintains consciousness

Neurologic deficits resolved in 1 hour

Complaints of the "worst headache of my life"

Answer and Explanation

The Correct Answer is D

A) Gradual onset of several hours:
Hemorrhagic strokes, particularly those caused by a ruptured cerebral aneurysm, typically present with sudden onset of symptoms rather than a gradual onset. The symptoms of a hemorrhagic stroke generally occur immediately or within minutes after the rupture.

B) Maintains consciousness:
While some patients may remain conscious initially after a cerebral aneurysm rupture, it is common for individuals with a ruptured cerebral aneurysm to experience loss of consciousness, or at least a decreased level of consciousness. The rupture causes an increase in intracranial pressure and often results in symptoms such as nausea, vomiting, and confusion, and may progress to coma or unresponsiveness.

C) Neurologic deficits resolved in 1 hour:
In the case of a hemorrhagic stroke, neurologic deficits do not typically resolve quickly, particularly after the rupture of a cerebral aneurysm. Neurological deficits associated with hemorrhagic strokes may include hemiparesis, aphasia, visual disturbances, and confusion. The concept of deficits resolving within 1 hour is more indicative of a transient ischemic attack (TIA).

D) Complaints of the "worst headache of my life":
One of the classic and most characteristic symptoms of a ruptured cerebral aneurysm (leading to hemorrhagic stroke) is a severe headache, often described by the patient as the "worst headache of my life." This sudden and intense headache occurs due to the bleeding into the subarachnoid space from the aneurysm rupture, which irritates the meninges and causes intense pain.

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Correct Answer is B

Explanation

A) Clubbing of the fingers
Clubbing of the fingers is typically associated with chronic hypoxia, often due to conditions like chronic obstructive pulmonary disease (COPD), congenital heart defects, or chronic respiratory disorders. While mitral valve stenosis can lead to pulmonary congestion and sometimes hypoxia, clubbing is not a hallmark finding of mitral valve stenosis.

B) A heart murmur
Mitral valve stenosis is commonly characterized by a heart murmur. The stenosis (narrowing) of the mitral valve obstructs blood flow from the left atrium to the left ventricle, leading to turbulent blood flow. This creates a characteristic diastolic murmur (a low-pitched, rumbling murmur heard best at the apex of the heart with the patient in the left lateral decubitus position).

C) Barrel chest
A barrel chest is more commonly associated with chronic obstructive pulmonary disease (COPD), emphysema, and other conditions that cause long-term hyperinflation of the lungs. It is not a typical finding in mitral valve stenosis. The shape of the chest may change over time in patients with severe left-sided heart failure, but this is not a primary or direct consequence of mitral valve stenosis.

D) Bradycardia
Bradycardia (a slow heart rate) is not a characteristic finding of mitral valve stenosis. In fact, mitral valve stenosis can lead to increased heart rates due to reduced cardiac output and compensatory mechanisms. As the left atrium becomes increasingly distended from the obstruction, atrial fibrillation (a rapid, irregular heartbeat) is common in mitral valve stenosis.

A. chemical burns to the posterior neck, chest, and back B. radiation burns to shoulder and bridge of nose C. electrical burns to the hands causing dysrhythmias D. thermal burns to the head, neck, face, and airway.

Correct Answer is D

Explanation

A) Chemical burns to the posterior neck, chest, and back:
Chemical burns primarily affect the skin and underlying tissues where the chemicals have come into contact. Although chemical burns can cause significant damage, particularly to the respiratory system if inhaled, chemical burns to the posterior neck, chest, and back would not typically require endotracheal intubation or tracheostomy unless there is evidence of inhalation injury or airway compromise.

B) Radiation burns to shoulder and bridge of nose:
Radiation burns, such as those from sunburn or therapeutic radiation, generally do not cause immediate airway compromise or respiratory distress unless the radiation exposure has affected the lungs or upper respiratory tract.

C) Electrical burns to the hands causing dysrhythmias:
Electrical burns can cause significant tissue damage, especially if there is a deep tissue injury and potential for electrical burns to the internal organs. They can lead to dysrhythmias, but these burns are more related to cardiac complications rather than direct airway injury. Endotracheal intubation may be required if there are signs of airway compromise or respiratory failure, but the primary concern with electrical burns would be cardiac monitoring and fluid resuscitation.

D) Thermal burns to the head, neck, face, and airway:
The upper airway (including the mouth, throat, and vocal cords) is particularly vulnerable to thermal injury from inhaling hot gases, smoke, or steam. This can lead to edema and airway obstruction, which can rapidly progress to respiratory failure. Endotracheal intubation or even a tracheostomy may be required to secure the airway and prevent suffocation. Inhalation injury is a significant concern in thermal burns involving the head, neck, and face.

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

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