A few days after a Cerebral Vascular Accident, the patient's family asks the nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response based on the knowledge that this drug must be used within:

4 hours

1 hour

24 hours

8 hours

Answer and Explanation

The Correct Answer is A

A. 4 hours:

This option indicates that tissue plasminogen activator (tPA) must be administered within 4 hours of the onset of stroke symptoms to be considered as a drug therapy option. tPA is a thrombolytic medication used to dissolve blood clots in ischemic stroke, and its effectiveness is highest when administered promptly after the onset of symptoms.

B. 1 hour:

Administering tPA within 1 hour of stroke onset would be extremely challenging and impractical. It typically takes time for patients to recognize stroke symptoms, seek medical attention, and undergo diagnostic evaluations before tPA administration. While time is of the essence in stroke treatment, 1 hour is too short of a timeframe for most patients to receive tPA.

C. 24 hours:

Administering tPA beyond 4.5 hours of stroke onset is generally contraindicated due to the increased risk of complications, including hemorrhagic transformation of the stroke. While there may be some extended time windows considered for certain patients under specific circumstances, such as those meeting eligibility criteria for extended thrombolytic therapy, 24 hours is outside the standard timeframe for tPA administration.

D. 8 hours:

While tPA administration within 8 hours of stroke onset may be feasible for some patients, it is beyond the standard recommended time window for optimal effectiveness. As mentioned earlier, tPA is most effective when administered within the first 3 to 4.5 hours after the onset of symptoms, with earlier administration associated with better outcomes.

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Correct Answer is C

Explanation

A. Extension of the extremities

Extension of the extremities is not consistent with decorticate posturing. Instead, it is more indicative of decerebrate posturing, where both the upper and lower extremities are typically extended.

B. Pronation of the hands

Pronation of the hands is not typically associated with decorticate posturing. In decorticate posturing, the hands are usually flexed with the wrists and fingers pointing towards the body.

C. Plantar flexion of the legs

Plantar flexion of the legs characteristic of decorticate posturing. Decorticate posturing mainly involves plantar flexion of the feet.

D. External rotation of the lower extremities

External rotation of the lower extremities is also not typically associated with decorticate posturing. In decorticate posturing, the lower extremities may exhibit extension or internal rotation, but external rotation is not a characteristic feature.

A. "It is too early to tell. When the spinal shock subsides, we will know more." B. "You should talk to your physician about things of that nature." C. "No. Significant recovery of function should occur in a few days." D. "Yes. In all likelihood, the paralysis is probably permanent."

Correct Answer is A

Explanation

A. "It is too early to tell. When the spinal shock subsides, we will know more."

This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.

B. "You should talk to your physician about things of that nature."

This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.

C. "No. Significant recovery of function should occur in a few days."

This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.

D. "Yes. In all likelihood, the paralysis is probably permanent."

This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.

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A few days after a Cerebral Vascular Accident, the patient's family asks the nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response based on the knowledge that this drug must be used within:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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