A patient complains of having the "worst headache" ever. The nurse realizes that this description is often seen in:
1. Intracranial hemorrhage
2. Ischemic stroke
3. Subarachnoid hemorrhage
4. A brain tumor
3
Rationale 1: Intracranial hemorrhage is a local hematoma in the brain that is manifested by neurologic symptoms such as a change in level of consciousness, and sensory and motor deficits.
Rationale 2: Ischemic stroke is characterized by confusion, difficulty speaking, visual disturbances, and sensory and motor deficits. Headache does occur.
Rationale 3: Subarachnoid hemorrhage is rupture of an aneurysm that releases blood directly into the cerebrospinal fluid under arterial pressure. The blood spreads rapidly, immediately increasing intracranial pressure. If bleeding continues, deep coma or death may result. Typically the bleeding lasts only a few seconds but there is risk of rebleeding. The classic symptom is a sudden, severe headache that begins abruptly and is described as "the worst headache of my life."
Rationale 4: The headache associated with a brain tumor is worse in the morning but improves during the day. It worsens with coughing, exercise, and changes in position. This type of headache does not respond to usual headache treatment.
You might also like to view...
During an admission assessment of an adolescent client, the nurse inquires about friends or peer groups. The adolescent smiles and jokingly tells the nurse that "I consider myself a loner and I don't need any friends."
The nurse's next action is to: 1. Ask the client how he/she gets along in school. 2. Ask the client to explain why he/she feels this way. 3. Document this in the admission assessment. 4. Encourage exploration of feelings.
A client living in the 1920s received health care services. Which of the following would have been the most likely form of payment?
a. Patients paid out of their pockets for whatever care the provider charged. b. Public health employees gave care to those who needed it. c. There was little health care to be had, regardless of a person's wealth. d. Workers who belonged to a union had their bills paid by insurance.
The client makes the statement: "I'm afraid to take the baby home tomorrow." Which response by the nurse would be the most therapeutic?
a. "You're afraid to take the baby home?" b. "Don't you have a mother who can come and help?" c. "You should read the literature I gave you before you leave." d. "I was scared when I took my first baby home, but everything worked out."
Which action by the nurse demonstrates fiscal responsibility to the patient? (Select all that apply.)
a. Discharging a patient home with prescriptions and no health insurance to cover the cost b. Assessing the patient's resources and determining their ability to pay for prescriptions c. Setting the patient up for Meals on Wheels d. Giving the patient information on free support groups e. Calling local churches to see what services they can offer the patient