The nurse suspects a subarachnoid hemorrhage in a patient admitted to the emergency department. Which of the following symptoms is commonly seen in a patient diagnosed with a subarachnoid hemorrhage?

Severe headache

Generalized weakness

Gradual blurry vision

Chest pain

Answer and Explanation

The Correct Answer is A

A. A severe headache, often described as a "thunderclap" headache or the worst headache of the patient’s life, is a classic symptom of subarachnoid hemorrhage due to irritation of the meninges and increased intracranial pressure.

B. Generalized weakness may occur in some neurological conditions but is not a hallmark symptom of subarachnoid hemorrhage.

C. Gradual blurry vision is more associated with conditions like increased intracranial pressure or other eye-related issues rather than acute subarachnoid hemorrhage.

D. Chest pain is not typically associated with subarachnoid hemorrhage; it may indicate other conditions such as myocardial infarction or pulmonary issues.

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Correct Answer is C

Explanation

A. While anxiety can cause gastrointestinal symptoms, the context of this patient’s experience with seizures indicates that it is specifically related to the seizure disorder rather than an independent anxiety issue.

B. The sensation of "butterflies" is not typically related to hunger, as hunger is more commonly associated with physical feelings of emptiness or pain rather than a specific butterfly sensation.

C. An aura is a perceptual disturbance experienced by some patients with seizure disorders that precedes a seizure. It can manifest as various sensations, including gastrointestinal feelings like "butterflies," which serve as a warning sign that a seizure is imminent.

D. A postictal sign refers to the state of confusion or altered consciousness following a seizure, rather than sensations experienced prior to the seizure.

A. Encourage the patient to cough to expectorate secretions B. Elevate the head of the bed to 30-45 degrees C. Stimulate the patient with active range of motion exercises D. Perform serial neurologic assessments while hospitalized E. Contact the healthcare provider if the ICP is sustained between 30-40mmHg

Correct Answer is ["B","D","E"]

Explanation

A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.

B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.

C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.

D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.

E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications

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The nurse suspects a subarachnoid hemorrhage in a patient admitted to the emergency department. Which of the following symptoms is commonly seen in a patient diagnosed with a subarachnoid hemorrhage?

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Naxlex Comprehensive Predictor Exams

A patient diagnosed with a seizure disorder tells the nurse that they feel like they have "butterflies" in their stomach. The patient has felt this in the past before having a seizure. The nurse recognizes that this feeling is:

Correct Answer is C

Explanation

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

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