For each assessment finding click to indicate whether these nursing interventions are appropriate or not appropriate. Each column must have at least one response option selected.

Rationale:

• Insert indwelling urinary catheter: Invasive procedures, including catheterization, should be avoided for at least 24 hours after fibrinolytic (Tenecteplase/tPA) administration due to the high risk of internal bleeding. If absolutely necessary, they should have been inserted before the medication was given.

• Assess family strengths and resources: Evaluating the family’s ability to assist with care is critical for discharge planning. Stroke patients often require support with ADLs and mobility, and early assessment promotes safer transitions and continuity of care.

• Perform range-of-motion exercises twice per day: To prevent contractures, joint stiffness, and muscle atrophy, passive and active range-of-motion exercises should be performed on affected limbs. Early mobility interventions reduce complications of immobility.

• Apply graduated compression stockings or SCDs: Stroke patients are at increased risk for deep vein thrombosis due to immobility. Compression devices or stockings facilitate venous return and help prevent thromboembolic events.

• Have an oral suction device available: Clients with dysphagia, decreased gag reflex, or impaired consciousness are at risk for aspiration. Having suction available ensures airway protection and prevents respiratory complications.

• Establish a nonverbal communication code system: Clients with aphasia or expressive communication deficits benefit from a nonverbal code system to express needs, which supports patient safety, reduces frustration, and facilitates care delivery.

Rationale:

• Hepatitis: The client’s elevated liver enzymes (AST 48 U/L, ALT 59 U/L), elevated bilirubin (3 mg/dL), and clinical signs such as jaundice and spider angiomas indicate liver inflammation and damage. These findings are consistent with alcoholic hepatitis, a condition caused by chronic alcohol consumption. The combination of laboratory abnormalities and physical assessment strongly supports hepatitis as the primary risk.

• Nephritis: There is no evidence of renal inflammation in the assessment. The client’s genitourinary function is within normal limits, and there are no laboratory findings suggesting elevated creatinine or hematuria.

• Cholecystitis: Although the client has jaundice, there is no reported right upper quadrant pain, fever, or Murphy’s sign, which are typical for gallbladder inflammation. Abdominal distension is more likely related to liver disease or ascites rather than cholecystitis.

• Chronic alcohol abuse: The client reports long-term, heavy alcohol use (12–16 beers daily for 2 years), which is the leading cause of hepatocellular injury in adults. Chronic alcohol intake disrupts liver metabolism, causes fat accumulation in hepatocytes, and increases the risk of alcoholic hepatitis, fibrosis, and cirrhosis. This risk factor directly explains the lab and clinical findings, making it the most relevant cause.

• Unmanaged hypertension: While the client has a history of untreated hypertension, it does not explain the elevated liver enzymes or jaundice. Hypertension increases cardiovascular risk but is not the primary factor causing hepatic injury.

• Viral infection: Viral hepatitis could cause similar laboratory and clinical findings, but there is no evidence of recent viral illness or laboratory confirmation. Chronic alcohol abuse is a more consistent explanation for the constellation of findings in this client.