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 A

Explanation

Choice A reason:

This is the correct answer because epidural steroid injections are used to treat radiculopathy by reducing inflammation and edema of the nerve root, which can relieve radicular pain and improve neurological function.

Choice B reason:

This is incorrect because local anesthetic alone can provide temporary pain relief by blocking nerve conduction, but it does not address the underlying cause of radiculopathy, which is nerve root compression.

Choice C reason:

This is incorrect because steroid and local anesthetic do not have any effect on the size or shape of the disc or bone spur that is compressing the nerve root. They only reduce inflammation and pain.

Choice D reason:

This is incorrect because although epidural injections may have fewer systemic side effects than oral or intravenous medications, they still have some risks and complications, such as infection, bleeding, nerve damage, or spinal headache.

A. Spurling's test. B. Straight leg raise test. C. Tinel's sign. D. Phalen's test.

Correct Answer is A

Explanation

Choice A reason:

This is the correct answer because Spurling's test is used to diagnose cervical radiculopathy by reproducing radicular pain with neck extension, lateral flexion, and compression. A positive result indicates nerve root compression by a herniated disc, osteophyte, or other lesion.

Choice B reason:

This is incorrect because straight leg raise test is used to diagnose lumbar radiculopathy by reproducing radicular pain with hip flexion and knee extension. A positive result indicates nerve root compression by a herniated disc or other lesion in the lower back.

Choice C reason:

This is incorrect because Tinel's sign is used to diagnose peripheral neuropathy by reproducing tingling or paresthesia with tapping over a damaged nerve. A positive result indicates nerve regeneration or irritation by a scar, tumor, or other lesion.

Choice D reason:

This is incorrect because Phalen's test is used to diagnose carpal tunnel syndrome by reproducing numbness or tingling in the median nerve distribution with wrist flexion for 60 seconds. A positive result indicates median nerve compression by a thickened flexor retinaculum or other lesion in the wrist.

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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

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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