A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
Gradual onset of headache.
Changes in consciousness.
Gradual onset of several hours.
History of neurologic deficits lasting less than 1 hr.
The Correct Answer is B
Choice A reason:
A gradual onset of headache is more characteristic of other types of headaches or conditions, such as tension headaches or migraines. Hemorrhagic strokes, particularly those caused by a ruptured cerebral aneurysm, typically present with a sudden and severe headache, often described as the “worst headache of my life.” This sudden onset is due to the rapid accumulation of blood in the brain, which increases intracranial pressure and causes immediate symptoms.
Choice B reason:
Changes in consciousness are a common manifestation of a hemorrhagic stroke. The sudden bleeding into the brain can disrupt normal brain function, leading to symptoms such as confusion, lethargy, or loss of consciousness. These changes occur rapidly and are a key indicator of a serious neurological event. The nurse should be vigilant for any alterations in the client’s level of consciousness, as this can signify worsening of the condition and the need for immediate medical intervention.
Choice C reason:
A gradual onset of several hours is not typical for hemorrhagic strokes. These strokes usually present with sudden and severe symptoms due to the abrupt rupture of a blood vessel in the brain. The rapid increase in intracranial pressure from the bleeding causes immediate and severe symptoms, rather than a slow progression over hours.
Choice D reason:
A history of neurologic deficits lasting less than 1 hour is more indicative of a transient ischemic attack (TIA), also known as a mini-stroke. TIAs are temporary and resolve within a short period without causing permanent damage. In contrast, a hemorrhagic stroke caused by a ruptured cerebral aneurysm results in immediate and severe symptoms that do not resolve quickly and require urgent medical attention.
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View Related questions
Correct Answer is D
Explanation
Choice A reason:
Restricting visitors to a few hours in the afternoon to promote client rest can help reduce fatigue, but it does not directly address the need to conserve energy throughout the day. While managing visitor times can be part of an overall strategy, it is not the most effective way to conserve energy for essential activities.
Choice B reason:
Scheduling all activities within a small block of time to allow the client a longer, uninterrupted rest period may lead to fatigue and decreased performance. Concentrating activities in a short time frame can be overwhelming and counterproductive, especially for clients with limited energy reserves.
Choice C reason:
Scheduling toilet breaks before and after any other planned activity is practical for managing personal needs but does not specifically address energy conservation. While it ensures that the client is comfortable, it does not optimize the timing of energy-intensive activities.
Choice D reason:
Scheduling energy-intensive activities at the time of day when the client has higher energy levels is the best approach to conserve energy without compromising physical or mental health. This strategy takes advantage of the client’s natural energy peaks, allowing them to perform activities more effectively and with less fatigue. It helps balance activity and rest, promoting overall well-being.
Correct Answer is B
Explanation
Choice A reason:
Recommending high-impact, vigorous exercises is not appropriate for clients with MS. These exercises can increase the risk of injury and exacerbate symptoms. Instead, low-impact exercises such as swimming, yoga, and stretching are more suitable for improving muscle strength and overall fitness without causing undue stress on the body.
Choice B reason:
Teaching the client stress management techniques such as deep breathing and meditation is an important intervention for managing MS. Stress can exacerbate MS symptoms, so learning effective stress management strategies can help the client maintain better control over their condition and improve their quality of life.
Choice C reason:
Advising the client to avoid social interactions to minimize stress is not a healthy recommendation. Social support is crucial for mental and emotional well-being. Instead of avoiding social interactions, the client should be encouraged to engage in supportive and positive social activities that do not cause stress.
Choice D reason:
Encouraging the client to void every hour is not a standard intervention for MS unless the client has specific bladder control issues. Bladder training and scheduled voiding may be recommended for clients with urinary symptoms, but this should be tailored to the individual’s needs and not applied universally.