Patient Data

Exhibits

The client is ready for transfer to the neurological intensive care unit (ICU). The receiving nurse obtains report from the emergency department (ED) nurse.

Received a computed tomography (CT) scan of the head 18 gauge peripheral IV (PIV) in bilateral antecubital spaces

CMP, WBC, APTT, PT/INR drawn and results are all WNL

12-Lead ECG normal sinus rhythm (NSR)

0.9% sodium chloride infusing at 50mL/hour

Sitting in a semi Fowler's position

Client is NPO

Pharmacy bringing tissue plasminogen activator (tPA) to the unit shortly

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

During tPA administration, the nurse should prioritize
dropdown
to monitor for
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

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.

Nursing Test Bank

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B,C"},"E":{"answers":"B"},"F":{"answers":"A,B,C"}}

Explanation

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.

A. Bacterial meningitis. B. Septic shock. C. Brain abscess. D. Viral encephalitis.

Correct Answer is A

Explanation

Rationale:

A. Bacterial meningitis: This condition is highly contagious and transmitted via respiratory droplets. A private room with droplet precautions is required to prevent the spread of infection to others.

B. Septic shock: Although serious, it is not typically contagious. The client needs intensive monitoring, but isolation is not necessary unless another transmissible condition is present.

C. Brain abscess: A brain abscess is not communicable and does not require isolation. It results from localized infection and can be managed safely in a shared room with appropriate care.

D. Viral encephalitis: Viral encephalitis is usually not spread person to person in a hospital setting. Standard precautions are generally sufficient unless another communicable disease is involved.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the clinical findings. For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B,C"},"E":{"answers":"B"},"F":{"answers":"A,B,C"}}

Explanation

The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available?

Correct Answer is A

Explanation

A client who weighs 110 lb receives a prescription for dalteparin 150 units/kg SUBQ daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing interventions should the nurse include in the client's plan of care? Select all that apply.

The nurse assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Patient Data Exhibits Click to indicate if the listed manifestations of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

A female client with degenerative disc disease and chronic sciatica is describing numbness and tingling down her left leg. Which assessment should the nurse obtain first?

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?