The client who has had open heart surgery for a mitral valve replacement with a mechanical valve is preparing for discharge. Which information should the nurse include in the teaching?

Take the prescribed anticoagulant specifically as directed

Stop taking your antihypertensive medications until checking with your surgeon

Avoid lifting objects ten pounds or greater for two days

Take your immunosuppressive medications daily in the morning

Answer and Explanation

The Correct Answer is A

A) Take the prescribed anticoagulant specifically as directed:
Clients with mechanical heart valves are at an increased risk of developing blood clots, and therefore, anticoagulation therapy (often warfarin or another blood thinner) is necessary to prevent thromboembolic events. It is essential for the client to take the prescribed anticoagulant exactly as directed, ensuring therapeutic levels are maintained while minimizing the risk of bleeding.

B) Stop taking your antihypertensive medications until checking:
This instruction is not appropriate after heart surgery. Antihypertensive medications are typically necessary to manage blood pressure and reduce the strain on the heart. Stopping antihypertensive medications without consulting the healthcare provider could result in elevated blood pressure, which can put undue stress on the heart, especially after valve replacement surgery.

C) Avoid lifting objects ten pounds or greater for two days:
This statement is not appropriate for a client who has undergone open heart surgery. After heart surgery, particularly valve replacement, the client may be advised to avoid lifting heavy objects for a period of time (often 4-6 weeks) to prevent strain on the incision site and the heart. Two days of restriction is insufficient; longer periods of activity limitation are usually required to ensure proper healing.

D) Take your immunosuppressive medications daily in the morning:
Immunosuppressive medications are not typically prescribed for clients with mechanical heart valves. Immunosuppressive drugs are usually prescribed for clients who have had organ transplants (e.g., kidney, liver) to prevent organ rejection. Since the client in this scenario had a mitral valve replacement, immunosuppressants are not usually indicated unless there are specific complications, such as endocarditis or other infections.

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Correct Answer is A

Explanation

A) Respiratory compromise
A spinal cord injury (SCI) at the level of C-3 (cervical spine) results in the loss of function of the diaphragm, which is innervated by the phrenic nerve originating from C-3 to C-5. As a result, the patient is at high risk for respiratory compromise and may require mechanical ventilation. Respiratory failure is a leading cause of death and complications in individuals with high cervical spinal cord injuries, particularly when the injury is at or above C-4.

B) Hypertension
Although spinal cord injuries can cause autonomic dysreflexia (a condition where the body’s autonomic nervous system overreacts to stimuli, leading to dangerously high blood pressure), this condition is more common in individuals with injuries above T6. At C-3, respiratory issues are the primary concern, and hypertension is not the leading cause of complications.

C) Septic shock
Septic shock can occur after any significant injury, especially if the individual develops infections (e.g., from urinary retention, pressure ulcers, or pneumonia). However, septic shock is not the main cause of complications or death related to a C-3 spinal cord injury.

D) Bradycardia
Bradycardia (a slow heart rate) can indeed be a concern in patients with SCI, especially those with injuries at or above the T1 level. However, at the level of C-3, the main cause of complications is respiratory failure, not bradycardia. While bradycardia can occur due to disruption of sympathetic nervous system control, respiratory compromise is the most critical immediate concern.

A. Fever and cardiac dysthymias B. Decline in neurological status and elevated blood pressure C. Abdominal distention and anorexia D. Positive Coombs test and low urine output

Correct Answer is B

Explanation

A) Fever and cardiac dysrhythmias:
Fever and cardiac dysrhythmias are not the hallmark signs of an intracerebral hemorrhage (ICH) following thrombolytic therapy. While fever can occur in the aftermath of a stroke, it is more commonly linked to infection or other complications. Cardiac dysrhythmias can occur in stroke patients due to autonomic dysfunction or other underlying conditions but are not specific to a hemorrhagic complication.

B) Decline in neurological status and elevated blood pressure:
A decline in neurological status (e.g., deterioration of consciousness, confusion, or focal deficits) and elevated blood pressure are classic signs of an intracerebral hemorrhage (ICH) following thrombolytic therapy, especially when tissue plasminogen activator (tPA) is administered. tPA works by dissolving blood clots but increases the risk of bleeding. An ICH could present with sudden worsening neurological symptoms, such as decreased level of consciousness, weakness, or sensory loss, and elevated blood pressure is a compensatory response to the hemorrhage.

C) Abdominal distention and anorexia:
Abdominal distention and anorexia are not typical indicators of an intracerebral hemorrhage following tPA therapy. These symptoms may indicate other issues, such as gastrointestinal problems or metabolic imbalances, but they are not directly related to hemorrhagic complications following thrombolytic therapy for stroke.

D) Positive Coombs test and low urine output:
A positive Coombs test indicates the presence of antibodies against red blood cells, which may suggest hemolytic anemia or an autoimmune process. Low urine output can result from a variety of conditions, including kidney dysfunction, dehydration, or shock, but these are not specific indicators of an intracerebral hemorrhage following tPA.

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The client who has had open heart surgery for a mitral valve replacement with a mechanical valve is preparing for discharge. Which information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

Correct Answer is A

Explanation

The nurse is caring for client who has had a stroke and who received tissue plasminogen activator(t-PA) 6 hours ago. The nurse identifies which of the following symptoms are indications of an intracerebral hemorrhage post thrombolytic therapy?

Correct Answer is B

Explanation

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