Why is it important for the nurse caring for a patient experiencing a stroke to establish the onset of the stroke before administering tissue plasminogen activator?

The activator is not recommended if the stroke onset is less than 3 hours.

The activator is recommended for transient ischemic attacks

The activator is recommended for patients with increased ICP.

The activator is not recommended if the stroke onset is greater than 3 hours.

Answer and Explanation

The Correct Answer is D

Rationale:
A. This is incorrect because tissue plasminogen activator (tPA) is most beneficial when given early, ideally within 3 hours of symptom onset (and up to 4.5 hours in selected patients). Early administration improves cerebral blood flow, limits infarct size, and enhances neurologic recovery. Therefore, onset less than 3 hours is not a reason to withhold tPA.

B. This is incorrect because transient ischemic attacks (TIAs) resolve spontaneously and do not involve persistent cerebral vessel occlusion. Since neurologic deficits are temporary and no active clot remains, tPA is not indicated and would expose the patient to unnecessary bleeding risk.

C. This is incorrect because increased intracranial pressure (ICP), often associated with cerebral edema or intracranial bleeding, is a contraindication to tPA. Administering a thrombolytic in this situation significantly increases the risk of intracranial hemorrhage and can worsen patient outcomes.

D. This is correct because tPA is not recommended if the onset of ischemic stroke symptoms occurred more than 3 hours ago (or beyond the extended window for select patients). After this time, brain tissue damage becomes irreversible, and the risk of hemorrhagic transformation outweighs the potential benefit. Establishing the exact time of onset is critical to determine eligibility and ensure safe administration of tPA.

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Correct Answer is C

Explanation

Rationale:
A. Exposure to nephrotoxic substances (e.g., certain antibiotics, contrast dye, or heavy metals) is a cause of intrarenal injury, but it is not the most common cause. It is a contributing factor in some cases of acute tubular necrosis.

B. Prolonged ischemia can damage renal tissues and lead to intrarenal injury, but the resulting damage often manifests as acute tubular necrosis, making ATN the final common pathway rather than the primary cause.

C. Acute tubular necrosis (ATN) is the most common intrarenal cause of acute kidney injury (AKI). ATN occurs when the tubular epithelial cells in the kidneys are damaged, usually due to ischemia, nephrotoxins, or a combination of both, leading to impaired kidney function and decreased urine output.

D. Hypotension for several hours is a prerenal cause of AKI because it reduces renal perfusion. If prolonged, it can lead to intrarenal injury such as ATN, but hypotension itself is classified as prerenal, not intrarenal.

A. Elevate the head of the bed to 10 degrees and keep the head in a natural position. B. Elevate the head of the bed to 30 degrees and keep the head in a neutral midline position. C. Keep the head of the bed flat with the head in a neutral midline position. D. Keep the head of the bed flat with the head in a natural position.

Correct Answer is B

Explanation

Rationale:
A. Elevating the head of the bed to 10 degrees is incorrect because 10 degrees is usually insufficient to promote optimal venous drainage from the brain. Keeping the head in a natural (turned) position can also impair venous return, potentially increasing ICP.

B. Elevating the head of the bed to 30 degrees with the head in a neutral midline position is correct. This position promotes venous drainage from the brain, reduces intracranial pressure, and maintains cerebral perfusion. Neutral alignment prevents kinking of the jugular veins, which could impede venous outflow. Elevating the head too much (>45 degrees) can decrease cerebral perfusion, while flat positioning can worsen ICP.

C. Keeping the head of the bed flat, even with the head in a neutral midline position, is incorrect because flat positioning increases venous congestion in the brain, which can raise ICP.

D. Keeping the head of the bed flat with the head in a natural (turned) position is incorrect for the same reason as C and adds risk of impaired venous drainage due to rotation of the neck, which can further elevate ICP.

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Why is it important for the nurse caring for a patient experiencing a stroke to establish the onset of the stroke before administering tissue plasminogen activator?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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