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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.
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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.
A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care?
- A. Elevate the head of the bed to 45 degrees.
- B. Maintain the patient on complete bed rest.
- C. Administer enemas when the patient is constipated.
- D. Avoid use of thigh-high elastic compression stockings.
Correct Answer: B
Rationale: Complete bed rest reduces BP and bleeding risk in aneurysms. HOB elevation varies, enemas are avoided, and compression stockings are often used.
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?
- A. Evidence of hemorrhagic stroke
- B. Blood pressure of 180/110 mm Hg
- C. Evidence of stroke evolution
- D. Previous thrombolytic therapy within the past 12 months
Correct Answer: A
Rationale: Thrombolytic therapy is contraindicated in hemorrhagic stroke due to bleeding risk. High BP, stroke evolution, or prior thrombolytic use are not absolute contraindications.
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.
During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.
- A. National Institutes of Health Stroke Scale (NIHSS) score
- B. Race
- C. LOC at time of admission
- D. Gender
- E. Age
Correct Answer: A,C,E
Rationale: NIHSS score, LOC, and age predict stroke outcomes. Race and gender are not significant predictors.