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?

Fever and cardiac dysthymias

Decline in neurological status and elevated blood pressure

Abdominal distention and anorexia

Positive Coombs test and low urine output

Answer and Explanation

The Correct Answer is B

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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Correct Answer is D

Explanation

A) Chemical burns to the posterior neck, chest, and back:
Chemical burns primarily affect the skin and underlying tissues where the chemicals have come into contact. Although chemical burns can cause significant damage, particularly to the respiratory system if inhaled, chemical burns to the posterior neck, chest, and back would not typically require endotracheal intubation or tracheostomy unless there is evidence of inhalation injury or airway compromise.

B) Radiation burns to shoulder and bridge of nose:
Radiation burns, such as those from sunburn or therapeutic radiation, generally do not cause immediate airway compromise or respiratory distress unless the radiation exposure has affected the lungs or upper respiratory tract.

C) Electrical burns to the hands causing dysrhythmias:
Electrical burns can cause significant tissue damage, especially if there is a deep tissue injury and potential for electrical burns to the internal organs. They can lead to dysrhythmias, but these burns are more related to cardiac complications rather than direct airway injury. Endotracheal intubation may be required if there are signs of airway compromise or respiratory failure, but the primary concern with electrical burns would be cardiac monitoring and fluid resuscitation.

D) Thermal burns to the head, neck, face, and airway:
The upper airway (including the mouth, throat, and vocal cords) is particularly vulnerable to thermal injury from inhaling hot gases, smoke, or steam. This can lead to edema and airway obstruction, which can rapidly progress to respiratory failure. Endotracheal intubation or even a tracheostomy may be required to secure the airway and prevent suffocation. Inhalation injury is a significant concern in thermal burns involving the head, neck, and face.

A. Equal but sluggishly reactive pupils B. Widening pulse pressure C. Altered level of consciousness D. Tachycardia and hypotension

Correct Answer is C

Explanation

A) Equal but sluggishly reactive pupils:
Pupillary changes, including sluggish or unequal responses, are significant signs of increasing intracranial pressure (ICP) and should be monitored closely. However, altered level of consciousness (LOC) is typically one of the earliest signs of increased ICP. The response of the pupils to light can become abnormal later, once pressure increases within the brain, particularly when brainstem function is impacted.

B) Widening pulse pressure:
A widening pulse pressure is part of Cushing’s triad, which is a late sign of increased ICP. Cushing’s triad consists of hypertension, bradycardia, and irregular respirations (often seen as Cheyne-Stokes). These changes occur in the later stages of elevated ICP as a compensatory mechanism to preserve cerebral perfusion. While this is an important finding, altered LOC would precede the development of Cushing’s triad.

C) Altered level of consciousness:
Altered level of consciousness (LOC) is typically the first and most sensitive indicator of increased ICP. As pressure increases within the skull, it compresses brain tissue and affects the brainstem, which controls basic functions like consciousness. LOC can range from mild confusion and disorientation to full loss of consciousness or coma, depending on the severity of the ICP increase.

D) Tachycardia and hypotension:
Tachycardia and hypotension can be associated with shock or other conditions, but they are not characteristic of early increased ICP. In fact, as ICP rises, the body typically responds with bradycardia (slower heart rate) and hypertension (increased blood pressure), which are part of the compensatory mechanisms.

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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?

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