Nokea
The experienced nurse is instructing the new nurse on subarachnoid hemorrhage. The nurse evaluates that the new nurse understands the information when the new nurse makes which statements? Select all that apply.
- A. “Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm.”
- B. “Subarachnoid hemorrhage occurs during sleep and is noticed when the client awakens.”
- C. “The client experiencing a subarachnoid hemorrhage may state having a severe headache.”
- D. “Tissue plasminogen activator (tPA) should be given to treat a subarachnoid hemorrhage.”
- E. “A subarachnoid hemorrhage often results in the cerebrospinal fluid appearing bloody.”
Correct Answer: A,C,E
Rationale: A subarachnoid hemorrhage is usually caused by rupture of a cerebral aneurysm. Ischemic stroke in older adults, not a subarachnoid hemorrhage, often occurs during sleep when circulation and BP decrease. Irritation of the meninges from bleeding into the subarachnoid spaces causes a severe headache. Thrombolytic therapy with tPA lyses clots and is contraindicated in subarachnoid hemorrhage. Bleeding into the subarachnoid space will cause the CSF to be bloody.
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The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?
- A. The elderly client who is experiencing a stroke in evolution.
- B. The client diagnosed with a transient ischemic attack 48 hours ago.
- C. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
- D. The client with Alzheimer's disease who is wandering in the halls.
Correct Answer: A
Rationale: A stroke in evolution (A) is an acute, progressing condition requiring experienced monitoring. TIA (B) is stable, Guillain-Barré pain (C) is manageable, and wandering (D) needs supervision but is less acute.
When the nurse monitors the client's neurologic status, which finding is most suggestive that the client's intracranial pressure is increasing?
- A. Widening pulse pressure
- B. Increased respiratory rate
- C. Elevated temperature
- D. Decreased level of consciousness
Correct Answer: A
Rationale: Widening pulse pressure is a hallmark sign of increasing intracranial pressure, often accompanied by bradycardia (Cushing's triad).
The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?
Correct Answer: 4 gtts/min
Rationale: Calculate: (25 mL/hr ÷ 60 min) × 10 gtts/mL = 4.17 gtts/min, rounded to 4 gtts/min.
The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his room. Which intervention should the nurse implement first?
- A. Insist that the client go to the dining room for meals.
- B. Notify the family of the change in behavior.
- C. Determine if the client wants another roommate.
- D. Complete a Geriatric Depression Scale.
Correct Answer: D
Rationale: Social withdrawal may indicate depression. Completing a Geriatric Depression Scale (D) is the first step to assess this possibility. Forcing dining (A), notifying family (B), or changing roommates (C) are premature without assessment.
Which intervention is most appropriate for a client diagnosed with Bell's palsy?
- A. Reduce the amount of light in the room.
- B. Advise the client to drink liquids from a straw.
- C. Inspect the buccal pouch for food after eating.
- D. Instruct the client on how to walk with a cane.
Correct Answer: B
Rationale: Drinking from a straw helps clients with Bell's palsy manage liquids, compensating for facial muscle weakness.