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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Using a cold compress is typically employed for reducing swelling or discomfort, but it does not address the visual deficits associated with homonymous hemianopia. This intervention would not assist the client in compensating for their visual field loss.
B. Teaching scanning techniques involves training the client to actively search for visual information from their affected side. This can include turning their head and using their eyes to scan to the left (for right homonymous hemianopia) or to the right (for left homonymous hemianopia). This compensatory strategy is crucial for helping the client navigate their environment safely and effectively during rehabilitation.
C. Applying an eye patch is not appropriate for homonymous hemianopia, as it may further limit visual input. In fact, patching could exacerbate difficulties by reducing overall vision and is generally more relevant for conditions like amblyopia or for treating diplopia (double vision), rather than compensating for a visual field deficit.
D. Using eye drops is typically for treating dry eyes, redness, or other ocular conditions, and does not directly address the issues related to homonymous hemianopia. This intervention would not help the client learn to compensate for their visual field loss.
Correct Answer is C
Explanation
A. While applying heat may help alleviate discomfort, it is not the primary recommendation for managing epididymitis. The treatment often involves rest, elevation of the scrotum, and possibly cold packs rather than heat. Therefore, while this statement may reflect some understanding, it is not the best indicator of comprehensive knowledge about managing epididymitis.
B. While some mild cases may improve spontaneously, most cases of epididymitis require treatment, especially if they are caused by infections, which are common. Untreated epididymitis can lead to complications, so this statement does not reflect an accurate understanding of the condition.
C. If epididymitis is caused by a sexually transmitted infection (STI), it is important that sexual partners be evaluated and treated as well to prevent reinfection. This indicates a proper understanding of the implications of the condition, particularly in the context of STIs.
D. It seems to reference concerns related to radiation therapy, which is unrelated to the management or understanding of epididymitis. This indicates a lack of focus on the current diagnosis and its implications.
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