A client is suspected to have a thoracic aortic aneurysm (TAA). What does the nurse assess for?

A. Obtain a STAT electrocardiogram (EKG).: An EKG evaluates cardiac rhythm and ongoing ischemic changes but does not assess neurological status. New disorientation during alteplase infusion raises concern for intracranial hemorrhage. Cardiac monitoring is important, but it does not address the immediate neurologic emergency suggested by acute mental status changes.

B. Call the primary health care provider immediately.: Alteplase is a fibrinolytic that increases the risk of bleeding, including intracranial hemorrhage. Sudden confusion and disorientation are early neurologic signs that may indicate cerebral bleeding. Immediate provider notification is critical so the infusion can be stopped and urgent neuroimaging, such as a CT scan, can be initiated to evaluate for hemorrhage.

C. Prepare the client for percutaneous cardiac intervention (PCI).: PCI is considered if thrombolytic therapy fails or if there is persistent ischemia. Disorientation is not an indication of failed reperfusion but rather a potential bleeding complication. Preparing for PCI would delay evaluation of a potentially life-threatening neurologic event.

D. Obtain STAT cardiac enzymes.: Cardiac enzymes help evaluate myocardial injury but are not useful in assessing acute neurologic deterioration. Elevated enzymes confirm myocardial infarction but do not explain sudden changes in mental status. The priority is evaluating for a hemorrhagic complication related to thrombolytic therapy.

A. Skin petechiae: Small, pinpoint red or purple lesions on the skin, known as petechiae, are caused by embolic phenomena from vegetations on the heart valves. They are a classic peripheral manifestation of infective endocarditis and support the diagnosis.

B. Friction rub heart sounds: A friction rub is associated with pericarditis, not endocarditis. It occurs when the pericardial layers rub against each other and is not a typical finding in infective endocarditis.

C. Hypothermia: Infective endocarditis generally presents with fever due to systemic infection. Hypothermia is uncommon and would suggest another underlying condition rather than supporting endocarditis.

D. Fever: Fever is the most common systemic manifestation of infective endocarditis. It results from the body’s inflammatory response to bacterial infection of the endocardial surfaces. Persistent or intermittent fevers are characteristic of this condition.

E. New onset murmur: The development of a new heart murmur indicates valve damage or regurgitation caused by vegetations on the heart valves. This is a cardinal cardiovascular sign of infective endocarditis.

F. Splinter hemorrhages on fingernails: Linear, reddish-brown lesions under the fingernails are caused by small emboli from valvular vegetations. Splinter hemorrhages are a classic peripheral sign supporting the diagnosis of infective endocarditis.