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 A
Explanation
A. Asking yes or no questions can help facilitate communication, as they require less verbal output from the client and can help the nurse understand the client’s needs or thoughts without overwhelming them
B. This option is somewhat useful, as practicing words can help the client regain some verbal skills. However, it may not be the most effective immediate intervention. Clients with expressive aphasia often struggle to produce speech rather than understand it, and they may not benefit as much from this approach without additional support from speech therapy.
C. This intervention is not beneficial for improving communication. Tracking time spent speaking could create additional pressure on the client and may contribute to frustration rather than facilitate communication. It does not address the underlying issue of expressive aphasia.
D. This is not an appropriate intervention. Changing the subject can confuse or frustrate the client further, making it more difficult for them to communicate. It does not support their efforts to express themselves and may discourage them from trying to communicate altogether.
Correct Answer is C
Explanation
A. While having multiple sexual partners is associated with an increased risk of sexually transmitted infections (STIs), it is not considered a significant risk factor for uterine cancer specifically. STIs can contribute to other reproductive cancers, such as cervical cancer, but they are not directly linked to the development of uterine cancer.
B. Smoking is a risk factor for various cancers, including cervical and lung cancers, but its association with uterine cancer is not as strong. While some studies suggest a potential link, it is not recognized as a primary risk factor for uterine cancer.
C. Prolonged exposure to unopposed estrogen (estrogen not balanced by progesterone) is the primary risk factor for uterine cancer. This can occur in situations such as obesity (where adipose tissue produces estrogen), hormone replacement therapy without progesterone, and certain medical conditions like polycystic ovary syndrome (PCOS).
D. Having multiple pregnancies is generally considered to have a protective effect against uterine cancer. Pregnancy reduces the number of menstrual cycles a woman has over her lifetime, which can lead to lower lifetime exposure to estrogen.
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