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.

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Correct Answer is A

Explanation

A. Assist the patient to turn to her side: This is the priority action to prevent aspiration of vomitus, which can be a serious complication for stroke patients who may have impaired swallowing and a reduced gag reflex.
B. Give an antiemetic as ordered: While important, administering an antiemetic should come after ensuring the patient’s safety and preventing aspiration.
C. Perform a test for blood on the emesis: This is not the immediate priority. Preventing aspiration is the first concern.
D. Call for an aide to get suction set up: Suction may be necessary if the patient is at risk of aspiration, but the first step is to turn the patient to prevent choking and aspiration.

A. Give the patient a glass of water. B. Check the patient's dysphagia screen C. Consult speech pathology. D. Teach that stroke patients are nothing by mouth (NPO)

Correct Answer is B

Explanation

A. Give the patient a glass of water.: Giving the patient water without assessing their swallowing ability can be dangerous due to the risk of aspiration.
B. Check the patient's dysphagia screen.: Assessing for dysphagia is crucial because stroke patients often have impaired swallowing, which increases the risk of aspiration and choking.
C. Consult speech pathology.: Consulting a speech pathologist is important for a comprehensive swallowing assessment, but it is not the immediate action when a patient requests water.
D. Teach that stroke patients are nothing by mouth (NPO).: Not all stroke patients are NPO. This decision is based on the patient's ability to swallow safely, determined by a dysphagia screen.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient recently admitted with a stroke. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A patient who is diagnosed with a stroke is requesting a glass of water. Which action is appropriate for the nurse to take?

Correct Answer is B

Explanation

Which factor would be the first step in the management of hypertension?

Which of the following are clinical manifestations of arterial occlusion? Select all that apply.

A patient asks the difference between osteoarthritis and RA. Which manifestations does the nurse explain are characteristic of RA? (Select all that apply.)

Which risk factors would be considered modifiable in the prevention of stroke? Select all that apply.

The nurse is assisting with the care of a patient with rheumatoid arthritis (RA). What should the nurse consider when providing care?

The LPN/LVP is discussing types of hypertension with a patient. Which statement by the patient would reflect understanding of secondary hypertension?

A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. (Select All that Apply.)

A nurse in an outpatient clinic is collecting data from a client who tells the nurse, "I have pain in my legs when I begin to walk, but the pain stops when I stop walking." Which of the following conditions should the nurse suspect?