A patient’s wife asks the nurse why her husband did not receive the clot-busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What is the best response by the nurse?
“He didn’t arrive within the timeframe for that therapy.”
“Not everyone is eligible for this drug. Has he had surgery lately?”
“You should discuss the treatment of your husband with his doctor.”
“The medication you are talking about dissolves clots and could cause more bleeding in your husband’s brain.”
The Correct Answer is D
tPA (tissue plasminogen activator) is a thrombolytic medication used only for ischemic strokes, where a clot obstructs blood flow. In a hemorrhagic stroke, the problem is bleeding rather than blockage, so administering tPA would worsen intracranial bleeding and increase the risk of death. The best response is to provide clear, accurate information in simple terms that reassure the wife and explain why her husband’s treatment is different. This promotes understanding, trust, and safety in care.
Rationale for correct answer:
4. “The medication you are talking about dissolves clots and could cause more bleeding in your husband’s brain.” This response directly addresses the wife’s concern while providing accurate education about why tPA is contraindicated. It is clear, compassionate, and avoids unnecessary medical jargon, helping the family understand the risk of worsening hemorrhage. Providing this explanation empowers the family with knowledge and helps prevent misconceptions about treatment.
Rationale for incorrect answers:
1. “He didn’t arrive within the timeframe for that therapy.” While time is critical for ischemic strokes, the main issue here is that the patient has a hemorrhagic stroke. This answer would be misleading and fail to address the real reason tPA was not given.
2. “Not everyone is eligible for this drug. Has he had surgery lately?” This is true for ischemic stroke patients, as recent surgery or bleeding risk may exclude them. However, it is not relevant in this case because the stroke is hemorrhagic, making tPA absolutely contraindicated.
3. “You should discuss the treatment of your husband with his doctor.” Although involving the doctor is appropriate, this answer avoids the nurse’s responsibility to provide accurate teaching. It may leave the wife feeling dismissed or more anxious.
Take-home points:
- tPA is only used for ischemic strokes, never for hemorrhagic strokes.
- In hemorrhagic stroke, giving tPA would worsen bleeding and increase mortality.
- Nurses must provide clear, honest explanations to families to build trust and understanding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A stroke is strongly associated with age, race, and hypertension, making certain individuals more vulnerable. African Americans have nearly twice the risk of a first stroke compared to whites, and hypertension is the single most important modifiable risk factor. Older adults with uncontrolled blood pressure are therefore at the highest risk among the listed groups. Early recognition of risk helps guide preventive interventions to reduce morbidity and mortality.
Rationale for correct answer:
4. 65-year-old African American man with hypertension. Hypertension is the leading cause of stroke because it damages arterial walls, accelerates atherosclerosis, and increases the likelihood of vessel rupture or occlusion. African American men not only have higher rates of hypertension but also higher rates of severe complications from it, including ischemic and hemorrhagic strokes. Age greater than 60 further increases risk, making this patient the most vulnerable.
Rationale for incorrect answers:
1. Obese 45-year-old Native American. While obesity is a significant risk factor for cardiovascular disease and stroke, this patient is younger and does not have a higher-risk comorbidity like hypertension. Although Native Americans do experience higher rates of diabetes and obesity, these factors alone do not surpass the combined risks of age, race, and hypertension in the correct choice.
2. 35-year-old Asian American woman who smokes. Smoking increases clot formation and accelerates atherosclerosis, raising stroke risk. However, this patient is relatively young, and her overall risk remains lower compared to an older hypertensive African American man. The protective factor of younger age offsets her smoking risk.
3. 32-year-old white woman taking oral contraceptives. Oral contraceptives slightly increase the risk of thrombotic stroke, especially in women who also smoke or have migraines with aura. Still, this patient is the youngest in the group and lacks additional high-risk conditions like hypertension or advanced age.
Take-home points:
- Hypertension is the single most important modifiable risk factor for stroke.
- African Americans are at higher risk of both incidence and complications from stroke.
- Age combined with chronic conditions such as hypertension significantly elevates stroke risk.
Correct Answer is C
Explanation
Urinary incontinence is a common complication after a stroke, often due to impaired mobility, cognitive changes, or loss of sphincter control. Effective bladder training focuses on restoring normal habits and encouraging voluntary voiding. For male patients, assisting the patient to stand to void uses natural body mechanics and gravity to promote bladder emptying. This strategy supports rehabilitation and helps the patient regain independence in urinary function.
Rationale for correct answer:
3. Assisting the patient to stand to void. Standing helps a male patient more effectively empty the bladder because it is the most natural and physiologic position for urination. This approach promotes muscle memory, encourages normal voiding patterns, and reduces the risk of urinary retention. It is an important component of rehabilitation and bladder retraining following stroke.
Rationale for incorrect answers:
1. Limiting fluid intake. Restricting fluids can lead to dehydration, urinary tract infections, and concentrated urine, which worsens bladder irritation. Adequate hydration is essential for urinary health and overall stroke recovery, making fluid restriction inappropriate for bladder training.
2. Keeping a urinal in place at all times. While convenient, leaving a urinal in place encourages dependence and does not retrain the bladder. The goal is to help the patient regain normal voiding habits rather than rely on a permanent external device.
4. Catheterizing the patient every 4 hours. Intermittent catheterization may be needed in cases of urinary retention, but routine catheterization increases the risk of infection and does not support retraining. It should not be used as a standard method for managing post-stroke incontinence.
Take-home points:
- Bladder training after stroke emphasizes restoring normal voiding patterns and independence.
- Standing to void is the best method for male patients, as it uses natural physiology to promote bladder emptying.
- Avoid strategies like fluid restriction, routine urinal use, or unnecessary catheterization, which do not support rehabilitation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.