When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min

BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min

BP 172/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

Answer and Explanation

The Correct Answer is D

A.   BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B.   BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C.   BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D.   The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

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Correct Answer is D

Explanation

A. Unable to discriminate words and letters is associated with left hemisphere damage, which is more linked to language and communication deficits.
B. Deficits in the right visual field would typically occur with left hemisphere damage, which affects vision.
C. Motor retardation is more often associated with left hemisphere damage affecting motor control.
D. Right cerebral hemisphere damage often results in behavioral changes, such as poor impulse control, lack of awareness of deficits (anosognosia), and changes in emotional responses.

A. Manifestations preceded by a severe headache B. Gradual onset of several hours C. History of neurologic deficits lasting less than 1 hr D. Maintains consciousness

Correct Answer is A

Explanation

A. A hemorrhagic stroke, especially after a ruptured cerebral aneurysm, often presents with a sudden, severe headache. This headache is typically described as the "worst headache of my life."
B. Gradual onset of several hours is more typical of an ischemic stroke, not a hemorrhagic stroke.
C. History of neurologic deficits lasting less than 1 hour would suggest a transient ischemic attack (TIA), not a hemorrhagic stroke.
D. Maintains consciousness is not typical of a hemorrhagic stroke, as the client may lose consciousness or be altered in their mental status due to the bleeding.

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When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is D

Explanation

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

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