Nokea
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.
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When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?
- A. Frustration around changes in function and communication
- B. Unmet physiologic needs
- C. Changes in brain activity during sleep and wakefulness
- D. Temporary changes in metabolism
Correct Answer: A
Rationale: Emotional responses post-stroke often stem from frustration with functional and communication deficits. Other causes should be ruled out.
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.
Stroke after a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following?
- A. Positioning to avoid hypoxia
- B. Maximizing PaCO2
- C. Administering hypertonic IV solution
- D. Initiating early mobilization
Correct Answer: A
Rationale: Positioning to avoid hypoxia reduces ICP in ischemic stroke recovery. High PaCO2 and early mobilization increase ICP; hypertonic saline is for hyponatremia.
A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family?
- A. The patient should mobilize as soon as she is physically able.
- B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.
- C. The patient should remain on bed rest until she expresses a desire to mobilize.
- D. Lack of mobility will greatly increase the patients risk of stroke recurrence.
Correct Answer: A
Rationale: Early mobilization prevents complications like contractures and DVT. Prolonged bed rest or waiting for patient initiative is not recommended.
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.