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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. The PNS consists of cranial and spinal nerves that connect the CNS to the rest of the body. B. The PNS is divided into two subdivisions: the somatic nervous system and the autonomic nervous system. C. The PNS controls voluntary movements of skeletal muscles and provides sensory feedback from the skin, joints, and muscles. D. The PNS regulates involuntary functions of smooth muscles, cardiac muscles, and glands.

Correct Answer is D

Explanation

Choice A reason:

This is a correct statement, as the PNS consists of cranial and spinal nerves that connect the CNS to the rest of the body and transmit sensory and motor signals.

Choice B reason:

This is a correct statement, as the PNS is divided into two subdivisions: the somatic nervous system (SNS) and the autonomic nervous system (ANS).

Choice C reason:

This is a correct statement, as the PNS controls voluntary movements of skeletal muscles and provides sensory feedback from the skin, joints, and muscles through the SNS.

Choice D reason:

This is an incorrect statement, as this is the function of the ANS, which is a subdivision of the PNS. The ANS regulates involuntary functions of smooth muscles, cardiac muscles, and glands through its two branches: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS).

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is reviewing the anatomy of the peripheral nervous system (PNS) with a group of nursing students. Which of the following statements by a student indicates a need for further teaching?

Correct Answer is D

Explanation

A nurse is teaching a client who has peripheral neuropathy about foot care. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is administering medication to a client who has Parkinson's disease. The client asks the nurse how the medication works. Which of the following responses by the nurse is appropriate?

A nurse is assessing a client who has peripheral neuropathy due to diabetes mellitus. Which of the following findings should the nurse expect?

A nurse is reviewing the medical history of a client who has ischemic stroke. Which of the following conditions is the most common cause of ischemic stroke?

A nurse is educating a client who has a history of ischemic stroke about modifiable risk factors. Which of the following risk factors should the nurse include in the teaching? (Select all that apply.)

A nurse is planning care for a client who has ischemic stroke and is at risk for cerebral edema. Which of the following interventions should the nurse include in the plan?

A client has been diagnosed with radiculopathy due to a herniated disc in the lumbar spine. The nurse should instruct the client to avoid which of the following activities? (Select all that apply.)