The rehabilitation nurse determines that the client who has had a hemorrhagic stroke is successfully adapting to functional changes if they:

use adaptive equipment in dressing self.

has difficulty with using modified feeding utensils.

experience bouts of depression and irritability.

get angry with the family if they interrupt a task.

Answer and Explanation

The Correct Answer is A

A.   Using adaptive equipment suggests they are finding ways to maintain independence and complete activities of daily living (ADLs) despite any physical or cognitive limitations. This is a positive sign of adaptation.
B.   Difficulty using modified feeding utensils suggests that the client is struggling to adapt to the changes caused by the stroke. If they cannot use these utensils effectively, it indicates a challenge in managing their eating independently, which is not a sign of successful adaptation.
C. While emotional responses like depression and irritability are common after a stroke, experiencing these feelings frequently can indicate difficulty in coping with the changes. This does not reflect successful adaptation; rather, it suggests that the client may be struggling emotionally and psychologically with their new circumstances.
D.   While frustration can be a normal response to challenges after a stroke, particularly in the context of regaining independence, getting angry at family members may indicate difficulty in coping with the changes or an inability to manage frustration.

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Correct Answer is C

Explanation

A. While blood vessel spasms can occur after a stroke, t-PA does not directly affect them.
B. Platelet aggregation is the process by which platelets stick together to form a clot. t-PA dissolves clots, but it does not prevent their formation.
C. Tissue plasminogen activator (t-PA) is a medication that can dissolve blood clots. In the case of a thrombotic stroke, a blood clot has blocked blood flow to the brain. By dissolving the clot, t-PA can restore blood flow and limit brain damage.
D. t-PA does not have any direct effect on the risk of infection in the brain.

A. Request medical prescription for an antibiotic such as gentamicin B. Obtain a full set of vital signs and have the client void in a specimen cup C. Increase intake of oral fluids such as cranberry juice D. Place the client in protective isolation

Correct Answer is B

Explanation

A. While antibiotics may be necessary if a UTI is confirmed, requesting a prescription would not be the immediate nursing action. The nurse must first assess the situation thoroughly and obtain necessary diagnostic information before medications can be prescribed.
B. This option is the most appropriate immediate action. Obtaining a full set of vital signs helps assess
the client’s overall condition, including the degree of fever and any signs of systemic infection. Collecting

a urine specimen will facilitate further evaluation, such as a urinalysis and culture, to confirm a UTI and identify the appropriate antibiotic treatment.
C. While increasing fluid intake can help with urinary tract health and dilute the urine, it is not an immediate priority in this situation. The client may need more urgent assessment and possible medical intervention rather than just dietary changes.
D. Although protective isolation may be warranted given the client’s immunocompromised state due to chemotherapy and radiation, it is not the immediate priority based on the current symptoms. The focus should first be on assessing and addressing the potential UTI.

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Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male: 451-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-155 g/dL
Hematocrit	42%-52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 10/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%


Platelets	150,000-450,000/mm3

The rehabilitation nurse determines that the client who has had a hemorrhagic stroke is successfully adapting to functional changes if they:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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