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 B

Explanation

A. Increase the client's oral fluid intake.: While staying hydrated is generally good, it doesn't directly address the issue of cold feet caused by reduced circulation.
B. Obtain a pair of slipper socks for the client.: Slipper socks can help keep the feet warm without constricting blood flow, which is important for comfort and promoting circulation.
C. Rub the client's feet briskly for several minutes.: Vigorous rubbing could potentially cause injury or worsen circulation issues due to the fragility of the tissues in vascular compromise.
D. Place a moist heating pad under the client's feet.: Moist heat is not recommended as it can increase the risk of burns and injury, especially if the client has reduced sensation due to vascular occlusion.

A. Asks patient to self-position leg B. Monitors dampness of cast and avoids moving it until it is dry C. Uses palms to move the cast D. Uses fingers to grasp cast

Correct Answer is C

Explanation

A. Asks patient to self-position leg: This is not advisable because the patient may not have the strength or capability to safely reposition the leg, especially if they are in pain or sedated.
B. Monitors dampness of cast and avoids moving it until it is dry: The cast may need to be moved before it is completely dry, for example, for patient comfort or to prevent pressure ulcers. Delaying repositioning may cause complications.
C. Uses palms to move the cast: This is the correct method. Using the palms prevents indentations in the cast that could create pressure points and lead to skin breakdown. Fingers can create pressure points that can dent the cast, compromising its integrity and potentially causing skin issues.
D. Uses fingers to grasp cast: Using fingertips can create indentations in the cast, which can lead to pressure sores or improper bone alignment.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

What is the term or acronym for a temporary impairment of cerebral circulation that causes symptoms lasting minutes to hours but results in no permanent neurological changes?

The nurse is caring for a patient with a fracture. Which complications should the nurse monitor for? Select all that apply.

A patient tells the nurse he has started experiencing erectile dysfunction since beginning treatment for hypertension. Which statement by the nurse is most appropriate?

A patient asks the nurse how to prevent a stroke. Which statement by the nurse is correct? Select all that apply.

The nurse is teaching a patient with an abdominal aortic aneurysm (AAA) about activity. Which statement made by the patient indicates an understanding of the teaching?

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

Which term(s) would the E's in the LIFESTYLE acronym represent when reinforcing teaching to a patient about lifestyle modifications? Select all that apply.

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