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:
“It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it.” While this response acknowledges the client’s feelings, it does not provide specific information about the benefits of cardiac rehabilitation. The client needs to understand how rehabilitation can help them recover and improve their quality of life.
Choice B reason:
“Diet and exercise are good for you and good for your heart.” This statement is true but too general. It does not address the client’s specific concerns about the purpose and benefits of cardiac rehabilitation. The client needs more detailed information about how the program can help them.
Choice C reason:
“Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.” This response directly addresses the client’s concerns and provides clear information about the benefits of cardiac rehabilitation. It explains that while the damage cannot be reversed, rehabilitation can help the client regain strength, improve cardiovascular health, and safely return to their daily activities.
Choice D reason:
“Your doctor is the expert here, and I’m sure they would only recommend what is best for you.” While this statement supports the doctor’s recommendation, it does not provide the client with specific information about the benefits of cardiac rehabilitation. The client needs to understand how the program can help them personally.
Correct Answer is B
Explanation
Choice A reason:
Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.
Choice B reason:
Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.
Choice C reason:
Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.
Choice D reason:
Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.