A patient who just suffered a hemorrhagic stroke is admitted through the emergency room. The nurse's primary assessment is focused on:
A) Cardiac and respiratory status
B) Seizure activity
C) Urinary output
D) Fluid and electrolyte balance
Ans: A
Feedback: Acute care begins with managing the ABCs. Patients may have difficulty keeping an open and clear airway secondary to a decreased level of consciousness. Neurological assessment with close monitoring for signs of increased neurological deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with a goal of adequate hydration to promote perfusion and decrease further brain activity.
You might also like to view...
A patient who has migraine headaches is prescribed sumatriptan [Imitrex] 5 mg unit-dose nasal spray. The patient has administered two sprays at 1400, 1600, and 1800 and calls to report little relief from headache pain
What will the nurse instruct the patient to do? a. Administer 2 sprays at 2000 and call the provider if no relief. b. Continue using 2 sprays every 2 hours as needed to relieve discomfort. c. Contact the provider to ask about using an ergot alkaloid medication. d. Use 3 sprays at the next dose to increase the dose.
The nurse is caring for a client who is scheduled for magnetic resonance imaging (MRI) of the heart. The client's history includes a previous myocardial infarction and pacemaker implantation. Which action by the nurse is most appropriate?
a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.
A review of the medical record reveals that a patient has been diagnosed with paroxysmal nocturnal dyspnea (PND)
Which questions would the nurse ask to assess the status of this condition? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "How often do you get up to go to the bathroom at night?" 2. "Are you still waking up at night because you are short of breath?" 3. "How long after you go to bed do you start having trouble breathing?" 4. "Do you still have to sleep on three pillows at night?" 5. "Are you still having palpitations at night?"
When is avoidance an effective stress reducer? (Select all that apply.)
a. When the stressor has great personal significance b. When the outcome of the event will not be affected c. When the stressor is not a frequently recurring event d. When continued avoidance does not add stress e. When avoidance does not diminish the self-image