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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Loss of appetite following surgery is common due to the body’s stress response and recovery process. While this may affect nutrition, it is not immediately concerning unless it persists or is associated with other symptoms like vomiting or fever.
B. Absent bowel sounds in the lower abdominal quadrants is a serious concern and requires nursing intervention. It could indicate ileus or bowel obstruction, both of which can lead to serious complications such as bowel perforation or peritonitis. If bowel sounds are absent and the client is post-surgery, this may need further assessment and intervention.
C. Mild pain at the surgical site when sitting up is typical after surgery, especially abdominal surgery. Mild pain or discomfort is expected in the early post-operative period and generally does not require urgent intervention unless it becomes severe or is unmanageable.
D. The client requires the use of a colostomy bag – This is an expected and necessary part of recovery for clients undergoing surgery to redirect intestinal contents. It does not indicate a complication but rather a standard post-operative outcome.
Correct Answer is B
Explanation
A. Dysphagia is a common symptom of esophageal cancer itself, not necessarily a sign of liver metastasis. Dysphagia occurs due to the tumor obstructing the esophagus.
B. Jaundice, characterized by a yellowing of the skin and sclera, can indicate liver dysfunction or metastasis to the liver. When cancer spreads to the liver, it can disrupt its normal functioning, leading to an accumulation of bilirubin in the body, causing jaundice.
C. Vomiting can occur in esophageal cancer due to obstruction or in advanced stages of the disease, but it is not a direct sign of metastasis to the liver.
D. Hypercalcemia can occur in some cancers, but it is not a typical manifestation of liver metastasis from esophageal cancer. It is more commonly seen in cancers such as breast, lung, or multiple myeloma.
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