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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instruct the client to perform controlled coughing and deep breathing.
This intervention is not appropriate for a client with increased intracranial pressure. Controlled coughing and deep breathing can increase intrathoracic pressure, which can in turn increase intracranial pressure. Therefore, this intervention should be avoided in clients with increased ICP.
B. Provide a brightly lit environment.
This intervention is not appropriate for a client with increased intracranial pressure. Bright lights can stimulate the reticular activating system and increase arousal, potentially exacerbating cerebral metabolic demand and intracranial pressure. Therefore, it is recommended to provide a calm, quiet environment with subdued lighting for clients with increased ICP.
C. Elevate the head of the bed 30°.
This intervention is correct. Elevating the head of the bed to 30 degrees promotes venous drainage from the head and reduces intracranial pressure. It helps prevent venous congestion in the brain and improves cerebral perfusion. This position is commonly used in clients with increased intracranial pressure to optimize cerebral blood flow.
D. Encourage a minimum intake of 2,000 mL/day of clear fluids.
This intervention is not appropriate for a client with increased intracranial pressure. While maintaining hydration is important for overall health, excessive fluid intake can increase intracranial pressure by increasing cerebral blood volume and cerebrospinal fluid production. Therefore, fluid intake should be carefully monitored and adjusted based on the client's condition and fluid balance.
Correct Answer is A
Explanation
A. "These drugs inhibit the action of acetylcholine":
This response is accurate. Anticholinergic medications work by blocking the action of acetylcholine, a neurotransmitter involved in various functions in the body, including muscle control. In Parkinson's disease, there is an imbalance between dopamine and acetylcholine, leading to motor symptoms such as tremors and rigidity. By inhibiting the action of acetylcholine, anticholinergic drugs help rebalance neurotransmitter activity and alleviate some of the motor symptoms associated with Parkinson's disease.
B. "These drugs help you urinate":
This statement is not directly related to the use of anticholinergic medications in Parkinson's disease. While some anticholinergic drugs can indeed relax the smooth muscle of the bladder and improve urinary symptoms, this is not the primary indication for their use in Parkinson's disease.
C. "These drugs will decrease your eye pressure":
While anticholinergic medications can be used to dilate the pupils and decrease intraocular pressure, this is not typically the reason for their use in Parkinson's disease. While some anticholinergic medications may have ocular effects, they are primarily used to address motor symptoms associated with Parkinson's disease.
D. "These drugs will assist in lowering your heart rate":
While some anticholinergic medications may have effects on heart rate by blocking parasympathetic nervous system activity, this is not the primary indication for their use in Parkinson's disease. The focus of anticholinergic therapy in Parkinson's disease is primarily on addressing motor symptoms rather than cardiovascular effects.
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