A client is being treated for an aneurysmal subarachnoid hemorrhage (SAH) that occurred 10 days ago
The nurse recognizes that the client is at risk for decreased cerebral blood flow and is especially concerned when the client: Select all that apply. 1. Has a temperature of 101? F.
2. Reports a stiff neck.
3. Seems unable to verbalize his needs.
4. Has unequal but reactive pupils.
5. Has difficulty starting his flow of urine.
1. Has a temperature of 101? F.
2. Reports a stiff neck.
3. Seems unable to verbalize his needs.
Rationale: Has a temperature of 101? F. The peak incidence of vasospasm is from 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. Reports a stiff neck. The peak incidence of vasospasm is from 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. Seems unable to verbalize his needs. The peak incidence of vasospasm is from 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. Has unequal but reactive pupils. Signs of vasospasm do not include abnormal pupil size or reaction. Has difficulty starting his flow of urine. Signs of vasospasm do not include urinary hesitation.
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