During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow?

A) RBCs 4.3 million/µL:
While a low RBC count can indicate anemia, the specific value provided here is not suggestive of anemia, and it does not explain the patient's symptoms of fatigue, weakness, and dizziness as clearly as a low hemoglobin would.

B) Potassium 4.8 mEq/L:
This result is not concerning and does not directly relate to the patient's reported symptoms of pallor, fatigue, and dizziness. Therefore, this lab result does not take priority in planning care at this time.

C) Hemoglobin of 9 g/dl:
This result is consistent with anemia, which is a likely cause of the patient’s symptoms of fatigue, weakness, dizziness, and pallor. Anemia can lead to decreased oxygen delivery to tissues, explaining the symptoms the patient is experiencing. The priority action for the nurse should be to address the underlying cause of anemia and manage it to improve the patient’s oxygenation and overall condition.

D) Sodium 137 mEq/L:
Although sodium imbalances can cause neurological symptoms such as confusion or lethargy, the patient’s reported symptoms of pallor, fatigue, and dizziness are more likely related to anemia. Sodium is not the most urgent concern for this patient at the moment.

A. GERD:
Gastroesophageal reflux disease (GERD) typically presents with symptoms such as heartburn, regurgitation, and chest pain. It is not related to head trauma or the symptoms described, such as severe headache, vomiting, seizure, and unresponsiveness. GERD is not associated with a fall or neurological events, making it an unlikely diagnosis in this scenario.

B. Hemorrhagic stroke:
A hemorrhagic stroke is a strong suspicion in this case, given the client’s recent fall, the report of a severe headache, vomiting, followed by a seizure and loss of consciousness. These are classic symptoms of increased intracranial pressure, which may result from bleeding in the brain, such as from a hemorrhagic stroke. The client’s hypertension (248/120 mmHg) further increases the risk of a hemorrhagic stroke, particularly in someone on long-term Warfarin, which increases the risk of bleeding. The seizure and unresponsiveness are concerning signs of significant brain injury, and a CT scan or MRI would be essential for confirming this diagnosis.
C. Septic shock:
Septic shock presents with hypotension, fever, tachycardia, and signs of infection. While the client’s elevated temperature (99.2 F) and pulse (102/min) are abnormal, they are not out of proportion to what would be expected with a head injury and potential hemorrhage. Septic shock is unlikely without signs of infection or systemic inflammatory response. The presence of a seizure, headache, and vomiting after trauma suggests a neurological emergency, not sepsis.

D. Absence seizure:
Absence seizures are brief, non-convulsive seizures characterized by a sudden interruption of consciousness, often with a blank stare and lack of motor activity. These seizures are typically seen in younger individuals and are not associated with symptoms such as a severe headache, vomiting, or unresponsiveness following head trauma. The client’s seizure, along with other concerning signs (headache, vomiting, high blood pressure), suggests a more serious neurological event like a hemorrhagic stroke rather than a simple seizure disorder.