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The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

A.

Generalized pain

B.

Alteration in level of consciousness (LOC)

C.

Tonic-clonic seizures

D.

Shortness of breath

Answer and Explanation

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 C

Explanation

A. "Try to buy and consume as many organic and natural foods as you can." While organic and natural foods are generally healthy, this advice does not directly align with the DASH diet, which focuses more on nutrient balance and reduction of sodium, fats, and sugars.

B. "Try to replace the complex carbohydrates in your diet with protein-rich foods." The DASH diet emphasizes balanced intake of whole grains (complex carbohydrates), fruits, vegetables, and lean proteins, rather than replacing complex carbohydrates.

C. "Try to reduce the overall amount of fat that is in your diet." This recommendation is consistent with the DASH diet, which advises reducing saturated fats and total fat to help manage blood pressure.

D. "If you eat four of five small meals each day, you'll find that you're able to reduce your calorie intake." Eating smaller, more frequent meals may help with calorie control, but this advice is more related to weight management than directly aligning with the DASH diet's focus on nutrient-rich, heart-healthy foods.

Correct Answer is C

Explanation

A. Bradycardia: Alcohol withdrawal typically presents with tachycardia (increased heart rate), not bradycardia (decreased heart rate).

B. Hypotension: Alcohol withdrawal is more likely to cause elevated blood pressure rather than hypotension.

C. Elevated temperature: Elevated temperature is a common sign of alcohol withdrawal, which can be accompanied by other symptoms like tremors and agitation.

D. Slurred speech: Slurred speech is more associated with alcohol intoxication rather than withdrawal.

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