A nurse is reviewing the electronic medical record of a middle-aged client who was admitted following a stroke. Which of the following findings should the nurse identify as a modifiable risk factor for stroke?
Hypertension
Client's age
History of sickle cell disease
Parent who has cardiovascular disease
The Correct Answer is A
Choice A Reason:
Hypertension is correct. This is a modifiable risk factor for stroke. Hypertension, or high blood pressure, significantly increases the risk of stroke. Treating and controlling hypertension through lifestyle changes and medication can help reduce the risk of stroke.
Choice B Reason:
Client's age is incorrect. While age itself is not modifiable, age is a non-modifiable risk factor for stroke. Risk of stroke increases with age, particularly in individuals over 55 years old. However, other modifiable risk factors can be addressed to reduce overall risk.
Choice C Reason:
History of sickle cell disease is incorrect. Sickle cell disease is a genetic disorder characterized by abnormal hemoglobin in red blood cells. While sickle cell disease increases the risk of certain complications, such as stroke in children, it is not a modifiable risk factor in the traditional sense.
Choice D Reason:
Parent who has cardiovascular disease is incorrect. While having a parent with cardiovascular disease may indicate a genetic predisposition to certain risk factors, it is not a direct modifiable risk factor for stroke. However, individuals with a family history of cardiovascular disease may have increased awareness and motivation to address modifiable risk factors such as hypertension, smoking, and diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason:
Muscle strength is correct. Assessing muscle strength is essential to determine if there are any neurological deficits or weakness that could indicate a neurological condition or injury. Sudden falls can be indicative of various neurological issues, such as stroke or transient ischemic attack (TIA). Assessing muscle strength helps identify any motor impairments or weakness that could contribute to the fall.
Choice B Reason:
Facial symmetry is correct. Assessing facial symmetry is crucial to identify any signs of facial droop, which could indicate a neurological deficit such as a stroke or Bell's palsy. Facial asymmetry may suggest damage to the facial nerve or other neurological issues.
Choice C Reason:
Peripheral pulses is incorrect. While assessing peripheral pulses is important for evaluating circulation, it may not be the priority assessment in this scenario where the client has suddenly fallen and may be experiencing neurological symptoms. Neurological deficits, such as weakness or changes in facial symmetry, vision, or speech, are more indicative of acute neurological issues like stroke or transient ischemic attack (TIA), which require immediate attention and intervention. In emergency situations, prioritizing assessments related to potential life-threatening conditions such as neurological deficits takes precedence over assessing peripheral pulses.
Choice D Reason:
Vision changes is correct. Assessing for vision changes is important to identify any visual disturbances or deficits that could contribute to falls or indicate underlying neurological issues such as a stroke or transient ischemic attack (TIA). Visual disturbances may include blurriness, double vision, or loss of vision in one or both eyes.
Choice E Reason:
Aphasia is incorrect. Assessing for aphasia, which is the inability to understand or express speech, is essential to identify any language deficits that could indicate a neurological condition such as a stroke. Aphasia may present as difficulty speaking, understanding language, or both.
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Temperature 36.3°C (97.4°F) is correct. Hypothermia is a characteristic finding in neurogenic shock due to the loss of sympathetic control over temperature regulation and peripheral vasodilation. This can lead to heat loss from the skin surface and a decrease in core body temperature.
Choice B Reason:
Respirations 12/min is incorrect. Respiratory rate is usually not significantly affected in neurogenic shock. However, individuals with high cervical or upper thoracic spinal cord injuries may experience respiratory compromise due to paralysis of respiratory muscles, but this is not a typical feature of neurogenic shock.
Choice C Reason:
Incorrect: Neurogenic shock typically results inhypotension(low blood pressure) due to vasodilation. The given blood pressure reading is elevated, which is not consistent with neurogenic shock.
Choice D Reason:
Heart rate 54/min is correct. Bradycardia is a common finding in neurogenic shock due to unopposed parasympathetic activity resulting from the loss of sympathetic tone. The heart rate may be slow and may decrease further over time.
Choice E Reason:
Calcium level 7.0 mg/dL is incorrect, Calcium levels are not directly related to neurogenic shock. Neurogenic shock primarily involves the loss of sympathetic tone and the resulting hemodynamic changes, rather than alterations in calcium metabolism.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.