Nokea
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.
You may also like to solve these questions
The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated. Put these steps in order in which they occur.
- A. 635241
- B. 352416
- C. 236145
- D. 162534
Correct Answer: C
Rationale: The ischemic cascade starts with decreased blood flow (2), then anaerobic respiration (3), lactic acid generation (6), pH change (1), membrane pump failure (4), and cell dysfunction (5).
A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?
- A. Female gender
- B. Asian American race
- C. Advanced age
- D. Smoking
Correct Answer: C
Rationale: Advanced age is a nonmodifiable stroke risk factor, with incidence doubling per decade after 55. Male gender, not female, and African American race are risks; smoking is modifiable.
The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image?
- A. Denial
- B. Fear
- C. Depression
- D. Disassociation
Correct Answer: C
Rationale: Stroke often leads to depression due to loss of function and independence. Denial, fear, or disassociation may occur but are less common responses to body image changes.
A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurses best answer?
- A. We are trying to help her be as useful as possible.
- B. The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible.
- C. We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home.
- D. Rehabilitation means helping patients do exactly what they did before their stroke.
Correct Answer: B
Rationale: Rehabilitation emphasizes restoring self-care to maximize independence. Other responses oversimplify or misrepresent rehabilitation goals.
A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care?
- A. The patient should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder.
- B. Elevation of the arm and hand can lead to further complications associated with edema.
- C. Passively exercising the affected extremity is avoided to minimize pain.
- D. The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
Correct Answer: D
Rationale: Interlacing fingers and moving scapulae forward safely exercises the shoulder, reducing subluxation pain. Slings are used, elevation prevents edema, and passive exercise is beneficial.