A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
The patient's blood pressure (BP) is 144/90 mm Hg.
The patient takes a diuretic because of a history of hypertension.
The patient has atrial fibrillation and takes warfarin (Coumadin).
The patient's speech is difficult to understand.
The Correct Answer is C
A. The patient's blood pressure (BP) is 144/90 mm Hg: While elevated blood pressure may contribute to the risk of intracerebral hemorrhage, the patient's current BP is not excessively high and may not be the most critical factor in this situation compared to other factors such as anticoagulant use.
B. The patient takes a diuretic because of a history of hypertension: While the patient's history of hypertension and diuretic use are relevant to their overall health status, they may not be the most immediate concern in the context of intracerebral hemorrhage.
C. The patient has atrial fibrillation and takes warfarin (Coumadin): This information is crucial as it indicates that the patient is anticoagulated, which can significantly impact the severity and management of intracerebral hemorrhage. Anticoagulant use increases the risk of bleeding and can worsen outcomes in cases of intracranial hemorrhage.
D. The patient's speech is difficult to understand: While difficulty with speech may indicate neurological impairment, it is not as immediately concerning as the patient's anticoagulant use, which increases the risk of bleeding complications and may require specific interventions such as reversal agents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing the client with the head reclined back can increase the risk of aspiration and is not recommended.
B. Placing food in the affected side of the mouth could lead to choking, as the client may have reduced sensation or control on that side.
C. Encouraging the client to take small bites can help prevent choking and make swallowing easier.
D. While exercise might promote appetite, it is not directly related to feeding safety and should be discussed separately from swallowing instructions.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Intracranial hemorrhage: Given the client's history of falling out of bed, subsequent head injury, headache, seizure, and neurological deterioration (weakness on the right side of the body, dilated right pupil, confusion), there is a significant concern for intracranial hemorrhage. These symptoms suggest possible bleeding within the skull, which can rapidly escalate and become life-threatening.
Heart rate: The client's decreasing heart rate from 70/min at 1230 to 40/min at 1430 indicates bradycardia, which can be a critical sign of increased intracranial pressure (ICP) due to intracranial hemorrhage. Bradycardia is a late sign of increased ICP and indicates severe neurological compromise. In this context, the irregular heart rate and the associated neurological symptoms raise concerns for impending or ongoing intracranial hemorrhage.
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