Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

The patient reports having a stiff neck.

The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

The patient reports a severe and unrelenting headache.

The patient's blood pressure (BP) is 90/50 mm Hg

Answer and Explanation

The Correct Answer is D

A. The patient reports having a stiff neck: While a stiff neck may indicate meningeal irritation, which can be associated with a subarachnoid hemorrhage, it is not as immediately concerning as hypotension, which can indicate hypovolemic shock or complications such as vasospasm.

B. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs): The presence of red blood cells in the cerebrospinal fluid is expected in a subarachnoid hemorrhage and is an important diagnostic finding but may not require immediate intervention.

C. The patient reports a severe and unrelenting headache: While a severe and unrelenting headache is a common symptom of subarachnoid hemorrhage, it is not as urgent as addressing hypotension, which can indicate hemodynamic instability and compromise perfusion to vital organs.

D. The patient's blood pressure (BP) is 90/50 mm Hg: Hypotension in a patient with a subarachnoid hemorrhage can indicate hypovolemic shock, vasospasm, or other complications. It is important to communicate this finding promptly to the healthcare provider for further
evaluation and management.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Engage in a vigorous exercise program." This statement may not be suitable for a client with multiple sclerosis experiencing symptoms such as diplopia, dysmetria, and sensory changes. While exercise is beneficial for managing MS symptoms, it should be tailored to the individual's abilities and symptoms.

B. "Plan to relax in a hot tub spa each day." Hot tubs can exacerbate symptoms of multiple sclerosis, particularly heat sensitivity. Therefore, this statement is not appropriate for this client.

C. "Implement a schedule to include periods of rest." Fatigue is a common symptom of multiple sclerosis, and incorporating regular periods of rest into the daily schedule can help manage fatigue and conserve energy.

D. "Wear an eye patch on the right eye at all times." While wearing an eye patch may help alleviate diplopia (double vision), it is not typically recommended for continuous use and should be used under the guidance of an ophthalmologist or healthcare provider.

A. Catheterize the patient every 3 to 4 hours. B. Administer medications to reduce bladder spasm. C. Assist the patient to ambulate 4 times daily. D. Stabilize the neck when repositioning the patient.

Correct Answer is B

Explanation

A. Catheterize the patient every 3 to 4 hours: Catheterization may be necessary for urinary retention, which is common in cauda equina syndrome, but it should not be done routinely every 3 to 4 hours. Indwelling catheters increase the risk of urinary tract infections and should be avoided unless necessary.

B. Administer medications to reduce bladder spasm: Bladder spasm is a common complication of cauda equina syndrome and can lead to urinary retention. Medications such as anticholinergics or alpha-adrenergic blockers may be prescribed to reduce bladder spasm and facilitate urine elimination.

C. Assist the patient to ambulate 4 times daily: Ambulation may not be appropriate for a patient with cauda equina syndrome, especially if they have significant motor or sensory deficits. Ambulation should be assessed on an individual basis and may require assistance or adaptive devices.

D. Stabilize the neck when repositioning the patient: Cauda equina syndrome affects the lower spinal cord and does not typically involve the cervical spine. Stabilizing the neck is important in patients with cervical spine injuries but is not directly related to cauda equina syndrome.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

Correct Answer is C

Explanation

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury?

Correct Answer is B

Explanation

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?