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.
You may also like to solve these questions
Which nursing intervention is best during the confusedness?
- A. Reading a newspaper or magazine to the client
- B. Informing the client that confusion is temporary
- C. Withholding verbal communication temporarily
- D. Reorienting the client to place and situation
Correct Answer: D
Rationale: Reorienting the client to place and situation reduces confusion and promotes safety post-craniotomy.
Which response by the nurse would be best to prevent distress when the client repeatedly asks, 'Where is my mother?'
- A. Explain to the client, 'Your mother died several years ago.'
- B. Tell the client, 'Your mother will visit later.'
- C. State, 'You miss your mother. What was she like?'
- D. Ask the client, 'When did you last see your mother?'
Correct Answer: C
Rationale: Redirecting the conversation to memories of the mother validates the client's feelings without causing distress from confronting reality.
Which type of precautions should the nurse implement for the client diagnosed with septic meningitis?
- A. Standard Precautions.
- B. Airborne Precautions.
- C. Contact Precautions.
- D. Droplet Precautions.
Correct Answer: D
Rationale: Meningococcal meningitis is transmitted via respiratory droplets, requiring Droplet Precautions (D) in addition to Standard Precautions. Airborne (B) and Contact (C) are not indicated.
When planning for the client's discharge after the diskectomy and spinal fusion, the nurse should include which instructions? Select all that apply.
- A. Avoid twisting or jerking the back.
- B. Wear a soft back brace at all times.
- C. Avoid sitting for long periods during the first week.
- D. Bend from the waist when picking up items from the floor.
- E. Monitor urine output for the first week.
- F. Report lower extremity color changes to the physician.
Correct Answer: A,C,F
Rationale: Avoiding twisting, prolonged sitting, and monitoring for neurological changes (e.g., color changes) promote recovery and prevent complications.
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?
- A. Awaken the client every two (2) hours.
- B. Monitor for increased intracranial pressure (ICP).
- C. Observe frequently for hypervigilance.
- D. Offer the client food every three (3) to four (4) hours.
Correct Answer: A
Rationale: For a mild concussion, monitoring for worsening neurological status is key. Awakening every 2 hours (A) allows assessment for altered consciousness. Monitoring ICP (B) is complex and not feasible at home, hypervigilance (C) is not typical, and frequent feeding (D) is unnecessary.