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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Correct Answer is C
Explanation
Choice A reason:
Inserting a padded tongue blade into the client’s mouth is not recommended and can be dangerous. During a seizure, there is a risk of causing injury to the client’s mouth or teeth, and it can also obstruct the airway. The correct approach is to ensure the client’s safety by preventing injury, not by inserting objects into their mouth.
Choice B reason:
Restraining the client during a seizure is not advised. Restraints can cause additional harm and do not prevent the seizure from occurring. Instead, the focus should be on protecting the client from injury by ensuring a safe environment and allowing the seizure to run its course.
Choice C reason:
Moving objects away from the client is a crucial step in ensuring their safety during a seizure. This action helps prevent the client from hitting or injuring themselves on nearby objects. Creating a safe space around the client is one of the primary goals during a seizure to minimize the risk of injury.
Choice D reason:
Placing the client on their back is not recommended during a seizure. Instead, the client should be placed on their side if possible, to help keep the airway clear and reduce the risk of aspiration. This position also allows for better monitoring of the client’s breathing and overall condition.
Correct Answer is C
Explanation
Choice A reason:
Home care services provide medical and personal care to clients in their homes. While this option may be suitable for clients with less severe symptoms, a client with significant bilateral lower extremities muscle weakness may require more intensive rehabilitation services to improve mobility and function.
Choice B reason:
A sub-acute care facility provides care for clients who need more intensive services than those available in a traditional nursing home but do not require the full resources of a hospital. While this option may be appropriate for some clients, a rehabilitation facility is better suited for addressing the specific needs of a client with significant muscle weakness due to MS.
Choice C reason:
A rehabilitation facility is the most appropriate setting for a client with significant bilateral lower extremities muscle weakness due to MS. These facilities offer specialized programs and therapies designed to improve mobility, strength, and overall function. The client can receive comprehensive care from a multidisciplinary team, including physical therapists, occupational therapists, and neurologists.
Choice D reason:
A skilled nursing facility provides long-term care for clients with chronic conditions or disabilities. While these facilities offer medical care and assistance with daily activities, they may not provide the intensive rehabilitation services needed for a client with significant muscle weakness due to MS.