Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

A right sided calcaneal spur

A blood pressure of 222/112 mmHg

Glycosylated hemoglobin of 5.9%

Recent endoscopy

Answer and Explanation

The Correct Answer is B

A.   A calcaneal spur, or heel spur, is a bony growth on the heel bone. This condition is primarily related to foot pain and does not have a direct link to the risk of stroke. It is not relevant in assessing stroke risk.
B.   This elevated blood pressure reading indicates hypertension, which is a significant risk factor for both ischemic and hemorrhagic strokes. Chronic high blood pressure can lead to damage of the blood vessels, making them more susceptible to rupture, thus increasing the risk of a hemorrhagic stroke.
C.   A glycosylated hemoglobin (HbA1c) level of 5.9% indicates well-managed diabetes, typically within the normal range for most individuals. While uncontrolled diabetes is a risk factor for vascular disease, this level suggests adequate control and does not specifically indicate an increased risk for a hemorrhagic stroke.
D.   A recent endoscopy itself does not indicate a direct risk for a hemorrhagic stroke. However, if the endoscopy was performed due to gastrointestinal bleeding or if it resulted in complications, there could be indirect implications, but this option alone does not signify an increased risk for hemorrhagic stroke.

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Correct Answer is C

Explanation

A. This intervention can be appropriate since a very low platelet count increases the risk of bleeding, including gastrointestinal bleeding. However, this action alone does not directly address the immediate risks associated with the low platelet count.
B. While hydration is important for overall health, this intervention does not specifically address the risks associated with a low platelet count. Additionally, excessive fluid intake may not be appropriate for all patients, especially if there are underlying kidney issues or fluid restrictions.
C. Clients with AML and low platelet counts are at increased risk for infections and may develop febrile neutropenia. Monitoring temperature every four hours can help detect early signs of infection, allowing for timely intervention.
D. While maintaining oral hygiene is important, especially in patients undergoing chemotherapy, this intervention may not be the most critical action based on the acute concern of a very low platelet count. However, it is important to note that patients with low platelet counts may also experience bleeding from the gums, making gentle oral care essential.

A. Increase and vary fluid intake B. Take an antipyretic such as aspirin every morning C. Use fragrance free gel soap to bathe D. Use analgesics as needed E. Install grab bars in the shower to prevent falls

Correct Answer is ["A","C","D","E"]

Explanation

A. Multiple myeloma can lead to dehydration and kidney problems. Increasing fluid intake helps to prevent these complications and can also help to reduce the risk of infections.
B. This statement is incorrect. Aspirin should not be taken unless prescribed by a doctor. It can increase the risk of bleeding in people with multiple myeloma.
C. Multiple myeloma can weaken the immune system, making the client more susceptible to infections. Using fragrance-free gel soap can help to reduce the risk of skin irritation and infections.
D. Multiple myeloma can cause bone pain. Using analgesics as needed can help to manage this pain and improve the client's quality of life.
E. Multiple myeloma can weaken bones, increasing the risk of fractures. Installing grab bars in the shower can help to prevent falls and reduce the risk of injuries.

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Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male: 451-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-155 g/dL
Hematocrit	42%-52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 10/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%

Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male 4.51-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-15.5 g/dL
Hematocrit	42% -52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 103/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%
Platelets	150,000-450,000/mm3

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is developing a discharge plan about home care for a client diagnosed with multiple myeloma. The nurse should emphasize which of the following? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D","E"]

Explanation

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