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A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurses best response to this assessment finding?
- A. Report this finding to the physician as an indication of decreased metabolism.
- B. Provide more stimulation to the patient and monitor the patient closely.
- C. Recognize this as the expected clinical course of a hemorrhagic stroke.
- D. Report this to the physician as a possible sign of clinical deterioration.
Correct Answer: D
Rationale: Increasing drowsiness indicates possible deterioration in hemorrhagic stroke, requiring immediate physician notification. It is not expected or due to metabolism, and stimulation is contraindicated.
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After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurses most appropriate action?
- A. Administer a bolus of normal saline as ordered.
- B. Prepare the patient for thrombolytic therapy as ordered.
- C. Facilitate testing for hypothalamic dysfunction.
- D. Prepare to administer 3% NaCl by IV as ordered.
Correct Answer: D
Rationale: Hyponatremia post-subarachnoid hemorrhage suggests SIADH or cerebral salt-wasting, treated with hypertonic 3% saline. Normal saline may worsen the issue, and other options are irrelevant.
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurses primary assessment focus?
- A. Cardiac and respiratory status
- B. Seizure activity
- C. Pain
- D. Fluid and electrolyte balance
Correct Answer: A
Rationale: Airway, breathing, and circulation (ABCs) are the priority in acute stroke to ensure airway patency and oxygenation. Seizures, pain, and fluid balance are assessed later.
Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patients plan of care?
- A. Supervise the patients activities of daily living closely.
- B. Initiate early ambulation to prevent complications of immobility.
- C. Provide a high-calorie, low-protein diet.
- D. Perform all of the patient's hygiene and feeding.
Correct Answer: A
Rationale: Close supervision of ADLs prevents exertion that could elevate BP in aneurysm precautions. Ambulation and dietary restrictions are not indicated, and some ADLs may be allowed.
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?
- A. Generalized pain
- B. Alteration in level of consciousness (LOC)
- C. Tonicclonic seizures
- D. Shortness of breath
Correct Answer: B
Rationale: Altered LOC, such as drowsiness or slurred speech, is the earliest sign of deterioration in hemorrhagic stroke. Pain, seizures, and shortness of breath are not typical early signs.
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?
- A. Sit with the patient for a few minutes.
- B. Administer an analgesic.
- C. Inform the nurse-manager.
- D. Call the physician immediately.
Correct Answer: D
Rationale: A severe headache may indicate aneurysm leakage, requiring immediate physician notification. Analgesics or sitting with the patient delays critical intervention.