The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:

reduce the risk of blood vessel spasm.

prevent platelet aggregation.

dissolve the blood clot.

prevent infection in the brain.

Answer and Explanation

The Correct Answer is C

A.   While blood vessel spasms can occur after a stroke, t-PA does not directly affect them.
B.   Platelet aggregation is the process by which platelets stick together to form a clot. t-PA dissolves clots, but it does not prevent their formation.
C.   Tissue plasminogen activator (t-PA) is a medication that can dissolve blood clots. In the case of a thrombotic stroke, a blood clot has blocked blood flow to the brain. By dissolving the clot, t-PA can restore blood flow and limit brain damage.
D.   t-PA does not have any direct effect on the risk of infection in the brain.

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Correct Answer is B

Explanation

A. A negative output would imply that the client has produced less urine than the irrigation received, which is not the case here.
B. The true urine output is 675 mL, calculated by subtracting the irrigation amount from the total urine collected.
C. The calculation does not support this value, as it does not accurately reflect the total urine output after accounting for the irrigation.
D. Similar to option A, a negative value does not apply here since the urine output exceeds the irrigation amount.

A. Impulsive behavior and hostility toward family B. Hemiparesis of the client's left arm and apraxia C. Homonymous hemianopia on the left side and diplopia D. Paralysis of the right side of the body and ataxia

Correct Answer is D

Explanation

A. These are behavioral changes that may occur after a stroke, but they are not directly related to motor loss.
B. Hemiparesis is weakness on one side of the body, but in this case, the client is experiencing motor loss on the right side. Apraxia is the inability to perform purposeful movements, which can also occur after a stroke, but it is not a direct manifestation of motor loss.
C. Homonymous hemianopia is the loss of vision in half of the visual field on the same side as the stroke. Diplopia is double vision. While these are both common symptoms of stroke, they are not related to motor loss.
D. A left-sided stroke typically results in motor loss on the right side of the body. This is because the left side of the brain controls the right side of the body. Additionally, ataxia, which is a lack of coordination, is a common symptom of stroke.

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ABG Value	Normal Range
PH	7.35-7.45
PaCO2	35-45 mm Hg
HCO3-	22-26 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is assessing a client experiencing motor loss as the result of a left-sided stroke. Which of the following clinical manifestations related to motor loss would the nurse document?

Correct Answer is D

Explanation

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