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

Answer and Explanation

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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Correct Answer is D

Explanation

A. This is not correct because a decrease in CEA levels typically indicates that the current treatment is having a positive effect on the cancer. If CEA levels were increasing, a change in the treatment plan might be considered, but this is not the case here.

B. An increase in CEA levels is typically associated with disease progression or metastasis, not a decrease. The reduction in CEA levels suggests that the cancer is responding to treatment, not progressing.

C. Tumor lysis syndrome occurs when a large number of cancer cells break down rapidly, releasing their contents into the bloodstream. It is more common with certain aggressive cancers or when large tumor burdens are rapidly shrinking. This client's decreasing CEA levels do not indicate that tumor lysis syndrome is more likely.

D. A decrease in CEA levels is a positive indicator that the chemotherapy is working and reducing the cancer burden, which is the desired effect.

A. Ice packs may be applied to the site for 30 minutes every hour for comfort B. Wear loose soft clothing over the treated area C. Do not share bathrooms or toilets with others for 48 hours after treatment D. Incorporate rest periods within the day

Correct Answer is B

Explanation

A. Applying ice packs to the radiated area is not typically recommended, as it can cause additional skin irritation or damage. Skin care after radiation usually focuses on keeping the skin moisturized and protected.
B. Wear loose soft clothing over the treated area is the most important instruction because radiation therapy can cause skin irritation and sensitivity. Wearing loose, soft clothing helps to avoid further friction or irritation on the sensitive skin in the treated area.
C. Avoiding sharing bathrooms or toilets with others for 48 hours after treatment is not a required precaution for external radiation therapy, as there is no significant risk of radiation exposure to others through contact with shared bathroom facilities. This is more applicable to certain types of radioactive implants or internal radiation therapies.
D. While rest is important during cancer treatment, this instruction is more general and not as specific to skin care management during radiation therapy. The primary focus for skin care would be preventing irritation and damage to the skin in the radiated area.

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 198 ng/mL and is now 95ng/mL. The nurse is aware this finding indicates the:

Correct Answer is D

Explanation

Which instruction is most important for the nurse to give a client who is receiving radiation therapy for lung cancer when teaching about skin care?

Correct Answer is B

Explanation

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