Marvin is transferred from the ICU to the Tele/Neuro unit 24 hours after receiving tPA. He has left sided hemiplegia with some dysphagia. What nursing interventions should be part of his plan of care? Select all that apply.

Ask the nursing assistant to determine if he can safely sit in a bedside chair.

Passive ROM exercise.

Assess neurologic status.

Coordinate with speech therapy to perform a swallowing evaluation.

Use pillows and positioning devices to maintain proper body alignment.

Pull on his arm to position him on his side.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A reason: Asking the nursing assistant to determine if Marvin can safely sit in a bedside chair is not appropriate. Safety assessments, especially for patients with recent neurological events, should be done by a registered nurse or a physical therapist. This ensures that any nuanced clinical signs indicating instability or risk are recognized and addressed promptly.
Choice B reason: Passive range of motion (ROM) exercises are essential for patients with hemiplegia to prevent complications such as muscle atrophy, joint contractures, and decreased circulation. Regularly performing these exercises can maintain the health of the muscles and joints, promote better blood flow, and help in maintaining some degree of flexibility in the affected limbs.
Choice C reason: Assessing neurologic status is crucial in patients who have had a recent stroke and received tPA treatment. Frequent neurologic assessments help in monitoring for any changes or signs of deterioration. This includes checking consciousness, pupil response, motor function, and sensory perception. Changes in these parameters can indicate complications or the need for immediate medical interventions.
Choice D reason: Coordinating with speech therapy for a swallowing evaluation is essential because Marvin has dysphagia. Swallowing assessments by a speech therapist can determine the patient's ability to swallow safely and the appropriate dietary modifications needed to prevent aspiration, a common risk in patients with dysphagia. This is vital to prevent pneumonia or other respiratory complications.
Choice E reason: Using pillows and positioning devices to maintain proper body alignment is important in preventing complications such as pressure ulcers, muscle contractures, and discomfort. Proper positioning can also assist in maintaining better respiratory function and overall comfort. It also prevents the development of deformities and promotes functional posture, which is especially important for patients with hemiplegia.
Choice F reason: Pulling on his arm to position him on his side is inappropriate and can cause injury, especially in a patient with hemiplegia. This technique can lead to shoulder dislocations or increased pain. Instead, proper repositioning techniques using assistive devices and help from additional staff members should be employed to ensure safe and effective movement of the patient.

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Correct Answer is ["C","E","F"]

Explanation

Choice A reason: Applying a clean, dry dressing over the VTE/DVT site is not necessary. VTE/DVT usually involves deep veins where there are no visible wounds requiring dressings. This instruction is irrelevant to the management and discharge instructions for a patient with DVT on anticoagulant therapy.
Choice B reason: Monitoring activated partial thromboplastin time (aPTT) results is relevant for heparin therapy, not for warfarin. Warfarin therapy is monitored using the international normalized ratio (INR). Therefore, this instruction is not appropriate for a patient being discharged on warfarin.
Choice C reason: Administering the warfarin dose at the same time each day is crucial for maintaining consistent blood levels of the medication, ensuring its effectiveness. It helps to maintain steady anticoagulation and reduces the risk of complications associated with fluctuating blood levels of warfarin.
Choice D reason: Instructing the patient to take aspirin or NSAIDs as needed for pain is inappropriate because these medications can increase the risk of bleeding when taken with warfarin. Patients on warfarin should avoid these medications and use alternatives like acetaminophen (Tylenol) for pain relief.
Choice E reason: Advising the patient to use electric razors, not straight razors, when shaving is important to prevent cuts and bleeding. Warfarin increases the risk of bleeding, and using an electric razor minimizes the chance of nicks and cuts that could lead to significant bleeding.
Choice F reason: Monitoring the level of anticoagulation with warfarin using INR results is essential. Regular INR monitoring ensures that the patient maintains a therapeutic level of anticoagulation and helps prevent both clotting and bleeding complications. Adjustments to the warfarin dose are made based on INR results.

A. ACE inhibitors B. Antibiotics C. Statins D. Beta-blockers E. Antiplatelet agents

Correct Answer is ["C","E"]

Explanation

Choice A reason: ACE inhibitors are primarily used to treat high blood pressure and heart failure, but they are not typically the first line of treatment for peripheral artery disease (PAD). While they may be prescribed to manage underlying conditions that contribute to PAD, they are not specifically targeted at improving blood flow in the affected arteries.
Choice B reason: Antibiotics are used to treat bacterial infections and have no role in the management of peripheral artery disease (PAD). They do not address the underlying causes or symptoms of PAD and are not included in the treatment regimen for this condition.
Choice C reason: Statins are commonly prescribed to patients with peripheral artery disease (PAD) as they help lower cholesterol levels and reduce the risk of plaque buildup in the arteries. By lowering LDL cholesterol and stabilizing plaques, statins can improve blood flow and reduce the progression of PAD.
Choice D reason: Beta-blockers are used to manage high blood pressure and heart conditions, but they are not typically used as a primary treatment for peripheral artery disease (PAD). While they may be prescribed to manage underlying cardiovascular conditions, they do not directly improve blood flow in the affected arteries.
Choice E reason: Antiplatelet agents, such as aspirin and clopidogrel, are commonly prescribed to patients with peripheral artery disease (PAD) to prevent blood clots from forming in the arteries. By inhibiting platelet aggregation, these medications help improve blood flow and reduce the risk of complications associated with PAD.

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Marvin is transferred from the ICU to the Tele/Neuro unit 24 hours after receiving tPA. He has left sided hemiplegia with some dysphagia. What nursing interventions should be part of his plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","E","F"]

Explanation

Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? Select all that apply:

Correct Answer is ["C","E"]

Explanation

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Which IV fluid is the most appropriate for treating acute Diabetes insipidus (DI)?

Order the steps for completing a blood transfusion.

A patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result would the nurse expect?

How is Addison disease treated and clinically managed?

Causative factors for the development of delirium include which of the following? Select all that apply.

In a severely anemic patient, which assessment findings would the nurse expect to find?