A nurse is providing teaching for a client who has a new prescription for promethazine tablets. Which of the following client statements indicates an understanding of the teaching?

When planning care for a client who had a myocardial infarction and is receiving thrombolytic therapy with an IV infusion of alteplase, the nurse should include the intervention of monitoring for changes in the client's level of consciousness.

Alteplase is a thrombolytic medication used to break down blood clots in certain medical emergencies, such as acute myocardial infarction (heart attack) or ischemic stroke. One of the potential complications of thrombolytic therapy, including alteplase, is bleeding. The medication's action of breaking down blood clots can also affect the body's natural clotting mechanisms, increasing the risk of bleeding.

Bleeding in the brain is a severe and potentially life-threatening complication associated with thrombolytic therapy. Therefore, it is essential for the nurse to closely monitor the client for any signs of intracranial bleeding, such as changes in the level of consciousness, confusion, severe headache, slurred speech, or weakness on one side of the body.

Let's go through the other options:

A. Administer aspirin instead of acetaminophen for fever: While aspirin is commonly used in the management of myocardial infarction, it is not specifically indicated for fever. Acetaminophen is the preferred antipyretic medication for fever management in most cases, and it does not interfere with the action of thrombolytic therapy.

B. Ambulate the client as often as tolerated: While early ambulation is beneficial for clients with myocardial infarction, it may not be appropriate during thrombolytic therapy. Thrombolytic therapy carries an increased risk of bleeding, and ambulation may be limited or contraindicated during the treatment period, depending on the client's overall condition and bleeding risk.

C. Administer a sodium phosphate enema for constipation: The administration of a sodium phosphate enema is not a specific intervention related to thrombolytic therapy or myocardial infarction. Bowel management is important for client comfort and overall well-being, but it is not a priority intervention in the immediate care of a client undergoing thrombolytic therapy.

The nurse should expect angioedema as one of the manifestations of anaphylaxis in a client experiencing an allergic reaction to an antibiotic. Angioedema is a severe swelling that occurs beneath the skin, typically affecting the face, lips, tongue, throat, or other body parts. It is a result of the release of histamine and other inflammatory mediators in response to the allergen.

Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and affect multiple body systems. In addition to angioedema, other common manifestations of anaphylaxis include:

• Difficulty breathing or wheezing due to bronchospasm

• Hives or urticaria, which are itchy raised skin rashes

• Severe itching or tingling sensation

• Rapid and weak pulse

• Low blood pressure leading to hypotension

• Nausea, vomiting, or diarrhea

• Feeling of impending doom or anxiety

Let's go through the other options:

A. Hypertonic reflexes: This is not a manifestation of anaphylaxis. "Hypertonic reflexes" are not typically associated with allergic reactions or anaphylaxis. Hypertonic reflexes refer to increased muscle tone, but they are not part of the usual presentation of anaphylaxis.

B. Increase in systolic blood pressure: Anaphylaxis usually leads to a decrease in blood pressure rather than an increase. The decrease in blood pressure can be severe and result in shock, which is a life-threatening condition.

D. Urinary retention: Urinary retention is not a common manifestation of anaphylaxis. Anaphylaxis primarily affects the respiratory and circulatory systems, leading to airway constriction, difficulty breathing, and cardiovascular collapse. Urinary retention is not directly related to the pathophysiology of anaphylaxis.