A patient is being treated for an aneurysmal subarachnoid hemorrhage (SAH) that occurred 10 days ago
The nurse recognizes that the patient is at risk for decreased cerebral blood flow and is especially concerned when which assessments are made? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient seems unable to verbalize needs.
2. The patient has difficulty starting the flow of urine.
3. The patient reports a stiff neck.
4. The patient has a temperature of 101°F.
5. The patient has unequal but reactive pupils.
1,3,4
Rationale 1: The peak incidence of vasospasm is 3 to 14 days from the incidence of SAH, although it may occur up to 21 days after the bleed occurs. Signs of vasospasm include aphasia.
Rationale 2: Signs of vasospasm do not include urinary hesitation.
Rationale 3: The peak incidence of vasospasm is 3 to 14 days from the incidence of SAH, although it may occur up to 21 days after the bleed occurs. Signs of vasospasm include neck stiffness.
Rationale 4: The peak incidence of vasospasm is 3 to 14 days from the incidence of SAH, although it may occur up to 21 days after the bleed occurs. Signs of vasospasm include fever.
Rationale 5: Signs of vasospasm do not include abnormal pupil size or reactivity.
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