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) “I will be able to recall events from childhood after completing rehabilitation”:
This demonstrates an unrealistic expectation. While rehabilitation can significantly improve cognitive functions, a serious brain injury may affect memory and recall to a degree that may not be fully reversible. Complete recovery of specific memories, such as childhood events, is not guaranteed.

B) "I will display all of my pre-injury traits and characteristics.":
This also reflects an unrealistic goal. Brain injuries can result in permanent changes to cognitive, emotional, and physical functioning. While rehabilitation can help a patient regain many abilities, it is unlikely that they will fully return to their pre-injury state, particularly in terms of personality traits and behaviors.

C) “I will regain complete motor and sensory functions after rehabilitation”:
This is also unrealistic. While rehabilitation aims to help patients regain as much motor and sensory function as possible, it is often not possible to fully restore complete function after a significant brain injury. Recovery may be partial, and some deficits may remain, depending on the extent of the injury.

D) “I should actively participate in the rehabilitation process as appropriate”:
This reflects a realistic and positive approach to recovery. Active participation in rehabilitation is essential for maximizing recovery after a brain injury. The process involves setting attainable goals based on the patient’s current abilities and gradually working toward improving those functions.

A. Tachycardia B. Crackles C. Ascites D. Dyspnea E. Peripheral edema

Correct Answer is ["A","B","D"]

Explanation

A) Tachycardia: Tachycardia is commonly seen in left-sided heart failure as the heart attempts to compensate for the reduced cardiac output. To maintain adequate perfusion, the body increases the heart rate. The sympathetic nervous system is activated, causing an increase in heart rate to try to pump blood more efficiently despite the reduced pumping ability of the left ventricle.

B) Crackles: Crackles (also known as rales) are typically heard upon auscultation of the lungs in patients with left-sided heart failure. When the left ventricle fails to effectively pump blood, it causes blood to back up into the lungs, resulting in pulmonary congestion. This leads to fluid accumulation in the alveoli, causing crackling sounds during inhalation.

C) Ascites: Ascites is more commonly seen in right-sided heart failure or in cases of congestive heart failure where both sides of the heart are affected. Ascites is the accumulation of fluid in the abdomen, which is a consequence of right-sided heart failure causing blood to back up into the abdomen. In left-sided heart failure, ascites is generally not a primary symptom unless the failure becomes severe and involves both sides of the heart.

D) Dyspnea: Dyspnea, or shortness of breath, is a hallmark symptom of left-sided heart failure. The left ventricle's inability to pump blood efficiently leads to pulmonary congestion, which causes fluid to accumulate in the lungs. This fluid buildup reduces the lung's ability to exchange oxygen, resulting in difficulty breathing, especially on exertion or when lying down (orthopnea).

E) Peripheral edema: Peripheral edema is more characteristic of right-sided heart failure due to the backup of blood in the systemic circulation. While it can occur in cases of biventricular heart failure (both right and left sides of the heart are affected), it is not the primary finding in left-sided heart failure. Left-sided heart failure typically presents with pulmonary symptoms rather than systemic symptoms like peripheral edema.

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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?

Nursing Test Bank

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