The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?
Generalized pain
Alteration in level of consciousness (LOC)
Tonic-clonic seizures
Shortness of breath
The Correct Answer is B
A. Generalized pain: Generalized pain is not a typical early sign of deterioration following a hemorrhagic stroke.
B. Alteration in level of consciousness (LOC): An alteration in LOC is often the earliest and most sensitive sign of neurological deterioration in clients who have had a hemorrhagic stroke. This can indicate increased intracranial pressure or further bleeding.
C. Tonic-clonic seizures: While seizures can occur after a stroke, they are not typically the earliest sign of deterioration. Changes in LOC usually precede seizure activity.
D. Shortness of breath: Shortness of breath may indicate respiratory issues but is not directly related to early neurological deterioration following a stroke.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.
B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.
C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.
D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.
Correct Answer is A
Explanation
A. Agranulocytosis: Carbamazepine carries a boxed warning for serious hematologic effects, including agranulocytosis and aplastic anemia. Agranulocytosis is a significant drop in white blood cell count, leading to a high risk of infection.
B. Birth defects: While carbamazepine is associated with birth defects when taken during pregnancy, the boxed warning specifically highlights the risk of severe blood disorders like agranulocytosis.
C. Skin rash: Carbamazepine can cause serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, but the boxed warning focuses more on the hematologic risks.
D. Liver damage: Although carbamazepine can cause liver damage, this is not the primary focus of the boxed warning, which emphasizes hematologic effects.
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