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 B
Explanation
Choice A reason:
Secondary prevention involves early detection and treatment of disease to halt its progression. Examples include screening tests and early interventions. Advising a client with osteoporosis to consume dairy products is not aimed at early detection but rather at preventing the onset of complications by ensuring adequate calcium intake.
Choice B reason:
Primary prevention aims to prevent the onset of disease or injury before it occurs. This includes measures such as vaccinations, lifestyle modifications, and dietary recommendations. Advising a client with osteoporosis to consume three servings of milk or dairy products daily is a primary prevention strategy. It helps to maintain bone density and prevent fractures by ensuring adequate calcium and vitamin D intake.
Choice C reason:
Proactive prevention is not a standard term used in public health or medical practice. The recognized levels of prevention are primary, secondary, and tertiary. Therefore, this option is not applicable in this context.
Choice D reason:
Tertiary prevention focuses on managing and mitigating the effects of an existing disease to prevent further complications and improve quality of life. This includes rehabilitation and ongoing treatment for chronic conditions. While advising a client with osteoporosis to consume dairy products can be part of managing the condition, it is primarily a preventive measure to avoid further bone loss and fractures, aligning more with primary prevention.