A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke
The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding?
A) Report this finding to the physician as an indication of decreased metabolism.
B) Provide more stimulation to the patient and monitor the patient closely.
C) Recognize this as the expected clinical course of a hemorrhagic stroke.
D) Report this to the physician as a possible sign of clinical deterioration.
Ans: D
Feedback:
Alteration in LOC often is the earliest sign of deterioration in a patient with a hemorrhagic stroke. Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is unlikely to be the result of metabolic changes and it is not expected. Stimulating a patient with an acute stroke is usually contraindicated.
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