A patient arrives in the emergency department at 0200 exhibiting signs and symptoms of a stroke. The patient went to bed at 2300 and was "feeling fine" but woke up at 0100 to go to the restroom and fell on the way there. The CT scan shows a hemorrhagic stroke. For what reason would tPA therapy be withheld?

tPA is not delivered for hemorrhagic stroke.

The total effects of ischemia are not currently known.

Too much time has passed since the symptoms began.

The patient's symptoms have progressed too quickly.

Answer and Explanation

The Correct Answer is A

A. tPA is not delivered for hemorrhagic stroke: This is correct. tPA is a thrombolytic medication used for ischemic strokes, not haemorrhagic strokes, as it would exacerbate bleeding.
B. The total effects of ischemia are not currently known: While assessing the extent of ischemia is important for ischemic stroke, it is irrelevant here because the stroke is hemorrhagic.
C. Too much time has passed since the symptoms began: The time window is important for tPA in ischemic strokes, but in this case, the type of stroke (haemorrhagic) is the determining factor.
D. The patient's symptoms have progressed too quickly: The progression of symptoms does not affect the decision to use tPA; the contraindication is solely due to the hemorrhagic nature of the stroke.

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 D

Explanation

A. Instruct the patient to wear constrictive clothing: This is incorrect. Constrictive clothing can impede blood flow and worsen venous stasis.
B. Encourage frequent ambulation: This is correct. Ambulation promotes circulation, helps prevent blood stasis, and encourages the healing of ulcers.
C. Encourage the patient to keep legs in a dependent position: This is incorrect. Keeping the legs in a dependent position can increase venous pressure and exacerbate edema, which is counterproductive for managing venous stasis ulcers.
D. Apply compression stockings: This is correct. Compression stockings help to improve venous return, reduce edema, and promote ulcer healing by preventing blood from pooling in the legs.

A. "Arteriolar vasoconstriction occurs, most often in the fingertips with symptoms of coldness, pain, and pale skin." B. "Peripheral vasospasm occurs in the lower limbs as a result of valve damage from long-standing venous stasis." C. "Arterial vessel occlusion is caused by many clots that develop in the heart and are carried to the bloodstream." D. "Thrombosis related to prolonged vasoconstriction caused by overexposure to the cold occurs."

Correct Answer is A

Explanation

A. "Arteriolar vasoconstriction occurs, most often in the fingertips with symptoms of coldness, pain, and pale skin.": Raynaud disease involves episodes of vasospasm in the small arteries and arterioles, primarily in the fingers and toes, leading to symptoms like coldness, pain, pallor, and sometimes color changes in the skin.
B. "Peripheral vasospasm occurs in the lower limbs as a result of valve damage from long-standing venous stasis.": This description is more characteristic of venous insufficiency or chronic venous stasis rather than Raynaud disease, which affects the small arteries in the extremities.
C. "Arterial vessel occlusion is caused by many clots that develop in the heart and are carried to the bloodstream.": This describes an embolic event rather than the vasospasm typical of Raynaud disease.
D. "Thrombosis related to prolonged vasoconstriction caused by overexposure to the cold occurs.": While exposure to cold can trigger Raynaud's symptoms, the primary issue is episodic vasospasm, not thrombosis. Raynaud’s is not characterized by blood clot formation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with venous stasis ulcers. What action should the nurse take?

Correct Answer is D

Explanation

A patient has been diagnosed with Raynaud's disease and asks the nurse what occurs with this disease. Which of the following is the most appropriate response?

Correct Answer is A

Explanation

A patient with peripheral arterial disease (PAD) is sitting in a chair and has cool feet that are reddish-purple in color. What action should the nurse take?

The nurse is teaching a patient about a thiazide-like diuretic. Which statement made by the patient indicates an understanding of the teaching?

The nurse is caring for a patient in hypertensive emergency. What should the nurse expect to be the goal when treatment is provided for this patient

A patient sustains a closed fracture of the right tibia and is placed in a long-leg plaster cast, which is still damp. Which of the following methods does the nurse use to move the cast when repositioning it to prevent complications?

The nurse contributes to the plan of care for a patient with hypertension. Which of the following nursing diagnoses is the focus of care for the patient with hypertension?

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Which tests can be used to assist in diagnosing a patient with peripheral arterial disease? Select all that apply. (Select All that Apply.)