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 incorrect because biceps brachii is innervated by C5-C6 nerve roots, which are not affected by a herniated disc at C6-C7 level.

Choice B reason:

This is the correct answer because triceps brachii is innervated by C6-C8 nerve roots, which are affected by a herniated disc at C6-C7 level.

Choice C reason:

This is incorrect because deltoid is innervated by C5-C6 nerve roots, which are not affected by a herniated disc at C6-C7 level.

Choice D reason:

This is incorrect because trapezius is innervated by cranial nerve XI (spinal accessory nerve), which is not affected by a herniated disc at C6-C7 level.

A. Elevate the head of the bed to 30 degrees. B. Administer mannitol as prescribed. C. Monitor the client's intracranial pressure. D. All of the above.

Correct Answer is D

Explanation

Choice A reason:

This is correct because elevating the head of the bed to 30 degrees can help reduce intracranial pressure by facilitating venous drainage and decreasing cerebral blood volume.

Choice B reason:

This is correct because administering mannitol as prescribed can help reduce intracranial pressure by creating an osmotic gradient that draws fluid out of the brain tissue and into the bloodstream.

Choice C reason:

This is correct because monitoring the client's intracranial pressure can help detect any signs of increased intracranial pressure or cerebral herniation, which can be life-threatening complications of cerebral edema.

Choice D reason:

This is correct because all of the above interventions are appropriate for a client who has ischemic stroke and is at risk for cerebral edema.

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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

A nurse is caring for a client who has cervical radiculopathy due to a herniated disc at C6-C7 level. Which of the following muscles should the nurse assess for weakness?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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