A nurse is caring for a client who has ischemic stroke and is receiving thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Which of the following actions should the nurse take? (Select all that apply.)

Monitor the client's vital signs and neurological status frequently.

Administer rtPA within 4.5 hours of symptom onset.

Maintain the client's systolic blood pressure below 180 mm Hg.

Give aspirin or other antiplatelet agents along with rtPA.

Assess the client for signs of bleeding or hemorrhagic transformation.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:
This is correct because monitoring the client's vital signs and neurological status frequently can help detect any changes in the client's condition, such as improvement or deterioration of symptoms, or complications such as bleeding or increased intracranial pressure.

Choice B reason:
This is correct because administering rtPA within 4.5 hours of symptom onset can increase the chances of restoring blood flow to the ischemic brain tissue and reducing neurological damage. The effectiveness and safety of rtPA decrease after this time window.

Choice C reason:
This is correct because maintaining the client's systolic blood pressure below 180 mm Hg can prevent further ischemia or hemorrhage in the brain. High blood pressure can increase the risk of bleeding or reperfusion injury after thrombolytic therapy.

Choice D reason:
This is incorrect because giving aspirin or other antiplatelet agents along with rtPA can increase the risk of bleeding or hemorrhagic transformation. Antiplatelet agents should be avoided for at least 24 hours after thrombolytic therapy.

Choice E reason:
This is correct because assessing the client for signs of bleeding or hemorrhagic transformation can help identify any adverse effects of thrombolytic therapy. Bleeding or hemorrhagic transformation can manifest as hematuria, hematemesis, melena, petechiae, ecchymosis, epistaxis, gingival bleeding, headache, altered mental status, or worsening neurological deficits.

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Correct Answer is B

Explanation

Choice A reason:

This is an incorrect answer, as seizures do not occur due to too much stimulation in brain cells, but rather due to abnormal electrical activity caused by neurotransmitter imbalance.

Choice B reason:

This is a correct answer, as seizures occur due to neurotransmitter imbalance, which disrupts communication between neurons and causes abnormal electrical activity in the brain.

Choice C reason:

This is an incorrect answer, as seizures do not occur due to lack of oxygen in brain tissue, but rather due to abnormal electrical activity caused by neurotransmitter imbalance.

Choice D reason:

This is an incorrect answer, as seizures do not occur due to infection in brain tissue, but rather due to abnormal electrical activity caused by neurotransmitter imbalance.

A. Expressive aphasia B. Receptive aphasia C. Global aphasia D. Anomic aphasia

Correct Answer is B

Explanation

Choice A reason:

This is incorrect because expressive aphasia is a type of aphasia that affects the ability to produce speech, but not to comprehend it. A client with expressive aphasia would be able to respond verbally, but with difficulty or errors.

Choice B reason:

This is the correct answer because receptive aphasia is a type of aphasia that affects the ability to comprehend speech, but not to produce it. A client with receptive aphasia would not be able to respond verbally, as they do not understand what is being asked.

Choice C reason:

This is incorrect because global aphasia is a type of aphasia that affects both the ability to produce and comprehend speech. A client with global aphasia would not be able to respond verbally or nonverbally, as they have no language function.

Choice D reason:

This is incorrect because anomic aphasia is a type of aphasia that affects the ability to recall specific words or names, but not the general ability to produce or comprehend speech. A client with anomic aphasia would be able to respond verbally, but with pauses or substitutions.

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A nurse is caring for a client who has ischemic stroke and is receiving thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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