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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Related Questions
Correct Answer is D
Explanation
A. Hypokalemia or hyponatremia: While electrolyte imbalances are important, they are not the most immediate threat in the context of a heroin overdose.
B. Acute gastrointestinal bleed: An acute gastrointestinal bleed is not a primary concern with heroin overdose. It is not the most acute threat in this scenario.
C. Increased intracranial pressure: Increased intracranial pressure is not directly related to heroin overdose. The most pressing issue is related to the effects of the overdose.
D. Respiratory depression: Heroin overdose commonly leads to respiratory depression, which is the most immediate and life-threatening condition. Addressing respiratory depression is crucial for patient survival.
Correct Answer is B
Explanation
A. Diarrhea: Opiates typically cause constipation, not diarrhea. Diarrhea is not a common finding with opiate use.
B. Pinpoint-sized pupils: Opiates commonly cause miosis, or pinpoint pupils. This is a classic sign of opiate use and is important for assessment.
C. Weight gain: Opiate use is not typically associated with weight gain; in fact, it can sometimes lead to decreased appetite and weight loss.
D. Bulimia: Bulimia is an eating disorder characterized by binge eating and purging. It is not a typical effect of opiate use.
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