Exhibits

The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.

Rationale:

• Avoidance: Avoidance of reminders of the trauma, including people, places, or conversations related to the event, is a core diagnostic criterion for PTSD. The client avoids visiting fellow platoon members, suggesting avoidance behavior linked to her combat trauma.
• Suicidal ideation: Thoughts of death or suicide are hallmark symptoms of MDD. The client was found writing a suicide note and planning to shoot herself, which strongly supports the diagnosis of MDD.
• Nightmares: Recurrent distressing dreams or nightmares related to the traumatic event are common in PTSD. The client reports frequent nightmares linked to her war experience.
• Feelings of guilt: Excessive guilt is common in MDD, often irrational and self-deprecating. In PTSD, survivors’ guilt is prevalent, especially when others died in the traumatic event, as expressed by the client lamenting that her life was spared over her comrades'.
• Lack of interest: Markedly diminished interest or pleasure in previously enjoyed activities is a core symptom of MDD. The client’s withdrawal from social connections reflects this loss of interest.
• Sleep disturbance: Insomnia is prevalent in GAD due to excessive worry, in MDD due to mood dysregulation, and in PTSD due to nightmares and hyperarousal. The client’s reported insomnia applies to all three conditions.

Rationale for Correct Choices:

• Frequent neurologic assessments: Frequent neurological checks are crucial during and after tPA administration to detect early signs of complications, particularly worsening neurological status, which may indicate intracranial bleeding. These assessments help ensure prompt intervention if deterioration occurs.
• Intracerebral hemorrhage: Intracerebral hemorrhage is the most serious and well-known risk of thrombolytic therapy. Monitoring for signs such as sudden headache, changes in consciousness, or worsening neurological symptoms is essential to detect this life-threatening complication early.

Rationale for Incorrect Choices:

• Continuous blood pressure monitoring: Although blood pressure control is important during tPA administration, continuous monitoring is not always required. Frequent checks (e.g., every 15 minutes) are typically sufficient unless there is an acute hypertensive crisis or rapid changes in neurological status.
• Hourly intake and output measuring: While intake and output may be monitored in ICU settings, this is not the priority during tPA administration. It does not help in detecting the most immediate and severe risk associated with thrombolytics.
• Pulmonary embolism: tPA is used to treat embolic events, not likely to cause them. Pulmonary embolism is not a known complication of thrombolytic therapy in ischemic stroke cases and would not be the primary concern during administration.
• Deep vein thrombosis: DVT is a potential complication from immobility in stroke patients, but not from tPA use. Monitoring for DVT is important during hospitalization but is not the priority during or immediately after tPA infusion.