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 D

Explanation

A. This option is primarily aimed at promoting lung expansion and preventing atelectasis (collapse of the lung). While it's an important post-operative intervention, it does not directly reduce the risk of embolic events related to venous thromboembolism.
B. Reporting significant pain (8/10) may indicate complications such as infection or improper healing, but it does not directly relate to reducing the risk of embolic events. While managing pain is important for recovery, simply reporting it does not contribute to preventing VTEs.
C. Assessing popliteal pulses is part of a thorough circulatory assessment, but it mainly focuses on blood flow to the lower extremities rather than preventing embolic events. It can help identify existing DVT but does not actively reduce the risk of embolism.
D. This statement is true and is the best choice for decreasing the risk of an embolic event. Early ambulation promotes venous return, improves circulation, and significantly lowers the risk of DVT and pulmonary embolism in post-operative patients. Encouraging patients to get out of bed and move around as soon as they are stable is a key nursing intervention in post-operative care.

A. notify the provider if the urine output is absent." B. resume voiding normally within one week." C. take a stool softener daily to decrease the chance of straining." D. monitor the skin around the surgical site for redness."

Correct Answer is B

Explanation

A. After a radical cystectomy, the client may have a urinary diversion (such as a stoma) and should be vigilant about monitoring urine output. Absence of urine output can indicate a serious issue, and notifying the provider is crucial.
B. This statement indicates a need for further clarification. After a radical cystectomy, clients typically do not resume normal voiding because the bladder is removed. Instead, they may have a urinary diversion or need to learn how to manage their new urinary output. Normal voiding as before surgery is not possible, so this statement reflects a misunderstanding of the procedure's implications.
C. After surgery, particularly abdominal surgery like a radical cystectomy, patients are often advised to take stool softeners to prevent constipation. Straining can increase the risk of complications and affect the surgical site, so this is a valid precaution.
D. Monitoring the surgical site for signs of infection, such as redness, swelling, or discharge, is an essential part of post-operative care. Clients should be educated on how to check their surgical site for any concerning changes.

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

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