The nurse is caring for client who has had a stroke and who has received tissue plasminogen activator (t-PA) 4 hours ago in the emergency department. During the nurse's initial assessment, which of the following signs and symptoms are indications of a complication post thrombolytic therapy? (SELECT ALL THAT APPLY)
Fever and Cardiac dysrhythmias
Elevated BP & patient reports headache
Positive Babinski’s sign
Patient has vomited once and reports nausea
decreased level of consciousness
Correct Answer : B,D,E
A. Fever and cardiac dysrhythmias are not specific complications of tissue plasminogen activator (t-PA) therapy. While they can occur after a stroke or as a general response to illness, they are not the primary indicators of complications related to thrombolytic therapy.
B. An elevated blood pressure combined with a headache could indicate a hemorrhagic transformation, which is a serious complication after t-PA administration. Thrombolytic therapy increases the risk of bleeding, and these symptoms may signal intracranial hemorrhage.
C. A positive Babinski's sign (extensor plantar response) is often seen in stroke patients as a neurological finding, but it is not specifically an indication of a complication from t-PA therapy. It is more reflective of the brain injury or stroke itself rather than the medication.
D. Nausea and vomiting can be signs of increased intracranial pressure (ICP), which could result from hemorrhage following t-PA therapy. This is a critical sign that requires immediate evaluation to rule out complications such as bleeding.
E. A decreased level of consciousness is a significant red flag and may indicate cerebral hemorrhage or another serious complication related to the administration of t-PA. Monitoring for changes in neurological status is crucial following thrombolytic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hospice care is intended for clients who are no longer pursuing curative treatment. The focus shifts from curing the disease to providing comfort, pain management, and emotional support at the end of life.
B. Hospice care is specifically for individuals who have a prognosis of 6 months or less to live, assuming the illness runs its normal course. This eligibility criterion is central to receiving hospice services.
C. Hospice care can be provided in various settings, including the client’s home, a hospice facility, a hospital, or a long-term care facility. Admission to a specific facility is not a requirement.
D. Hospice care focuses on symptom management, pain control, and quality of life for clients who are terminally ill. The interdisciplinary hospice team addresses the physical, emotional, spiritual, and social needs of the client.
Correct Answer is B
Explanation
A. Waxed dental floss is generally safe for most patients, including those receiving chemotherapy. It is important to be gentle when flossing to avoid injuring sensitive gums, which may be more prone to bleeding during chemotherapy due to reduced platelet count.
B. Alcohol-based mouthwashes should be avoided during chemotherapy because they can cause dryness and irritation to the mucous membranes in the mouth, which are already sensitive due to the side effects of chemotherapy. Alcohol can exacerbate mucositis (inflammation of the mucous lining) and increase discomfort.
C. Soaking dentures in hydrogen peroxide is generally safe for denture care, as hydrogen peroxide can be used to disinfect dentures. However, it is important to ensure that dentures are thoroughly rinsed after soaking to avoid irritation to the mouth.
D. Using a soft-bristled toothbrush is safe and recommended. A soft-bristled toothbrush is ideal for patients receiving chemotherapy, as their gums and mouth may become more sensitive. Brushing gently can help maintain oral hygiene without causing injury.
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