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. These are behavioral changes that may occur after a stroke, but they are not directly related to motor loss.
B. Hemiparesis is weakness on one side of the body, but in this case, the client is experiencing motor loss on the right side. Apraxia is the inability to perform purposeful movements, which can also occur after a stroke, but it is not a direct manifestation of motor loss.
C. Homonymous hemianopia is the loss of vision in half of the visual field on the same side as the stroke. Diplopia is double vision. While these are both common symptoms of stroke, they are not related to motor loss.
D. A left-sided stroke typically results in motor loss on the right side of the body. This is because the left side of the brain controls the right side of the body. Additionally, ataxia, which is a lack of coordination, is a common symptom of stroke.

A. "I should not exercise if I develop a leg ulcer." B. "I should buy my shoes in the afternoon." C. "I should dangle my legs when sitting." D. "I must wear compression stockings at all times."

Correct Answer is D

Explanation

A. While it's true that ulcers can be a serious complication of PAD and require careful management, exercise is generally encouraged in patients with PAD as long as it is safe and supervised. Patients should consult their healthcare provider about appropriate exercise, but not exercising altogether can worsen their condition.
B. Buying shoes in the afternoon is advisable because feet can swell throughout the day. It helps ensure a better fit and reduces the risk of blisters or skin breakdown, which is particularly important for clients with PAD.
C. This statement is generally correct, as dangling the legs can help improve circulation in some cases. Clients with PAD often experience relief when their legs are in a dependent position, as it may help increase blood flow to the extremities. However, they should also be encouraged to avoid prolonged periods of sitting.
D. This statement may indicate a misunderstanding. Compression stockings are typically used for venous issues rather than arterial diseases like PAD. In patients with PAD, wearing compression stockings may not be appropriate and could potentially compromise arterial blood flow.

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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%


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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The nurse is assessing a client experiencing motor loss as the result of a left-sided stroke. Which of the following clinical manifestations related to motor loss would the nurse document?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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