While teaching a wellness class on the warning signs of stroke, a ...

[Starlight]

While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, What's the most important thing for me to remember?
 
  What is an appropriate response by the nurse?
  A) Be alert for sudden weakness or numbness.
  B) Know your family history.
  C) Keep a list of your medications.
  D) Call 911 if you notice a gradual onset of paralysis or confusion.

Question 2

A nurse working in the intensive care unit (ICU) is caring for a client in progressive hemorrhagic shock. When planning care for this client, which does the nurse anticipate?
 
  A) A sustained decrease of 10mmHg of the client's mean arterial pressure (MAP)
  B) A blood loss of 25
  C) A change from aerobic to anaerobic metabolism
  D) A decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space

[kusterl]

Answer to Question 1

Answer: A

Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance-the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.

Answer to Question 2

Answer: C

In intermediate or progressive hemorrhagic shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35 to 50. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.