A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?
A client who has an arteriovenous malformation
A client who has thrombocytopenia
A client who has chronic atrial fibrillation
A client who has uncontrolled hypertension
The Correct Answer is C
A client who has chronic atrial fibrillation is at risk for an ischemic embolic stroke. An ischemic embolic stroke occurs when a blood clot that forms in one part of the body travels to the brain and blocks blood flow. Atrial fibrillation is a type of irregular heart rhythm that can cause blood to pool, thicken, and clot in the heart or arteries near it. Pieces of these clots can travel to the brain and cause an ischemic embolic stroke.
a. A client who has an arteriovenous malformation is not at risk for an ischemic embolic stroke.
b. A client who has thrombocytopenia is not at risk for an ischemic embolic stroke.
d. A client who has uncontrolled hypertension is at risk for a stroke but not specifically an ischemic embolic
stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.
a. Peripheral edema is not a manifestation of increased intracranial pressure. Peripheral edema is swelling in the extremities and can be caused by a variety of conditions.
b. Diarrhea is not a manifestation of increased intracranial pressure. Diarrhea is loose or watery stools and
can be caused by a variety of conditions.
c. Decreased pedal pulses are not a manifestation of increased intracranial pressure. Decreased pedal
pulses can indicate poor circulation to the feet and can be caused by a variety of conditions.
Correct Answer is A
Explanation
The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.
Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.
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