A client admitted to the Emergency Department with a suspected STEM. The nurse anticipates that this client will be immediately prepared for the cardiac catheterization laboratory as the goal of treatment is to:

Measure heart chamber pressures to assess for heart failure

Determine cardiac output during the procedure.

Evaluate the extent of the occlusion of the coronary arteries involved

Prevent extensive myocardial damage

Answer and Explanation

The Correct Answer is D

A) Measure heart chamber pressures to assess for heart failure:
Measuring heart chamber pressures is an important diagnostic tool in assessing heart failure, but it is not the primary goal in the case of a STEMI (ST-Elevation Myocardial Infarction). In STEMI, the primary goal is to identify and treat the blockage in the coronary arteries that is causing the heart attack.

B) Determine cardiac output during the procedure:
Cardiac output is a useful measurement for assessing heart function, but it is not the main focus during the treatment of STEMI. While monitoring cardiac output may be part of the overall care, the urgent priority in STEMI management is to restore blood flow to the affected myocardial tissue as quickly as possible to minimize damage, not to measure cardiac output.

C) Evaluate the extent of the occlusion of the coronary arteries involved:
While evaluating the extent of coronary artery occlusion is part of the process during a cardiac catheterization, the immediate priority for a patient with STEMI is to treat the blockage, not just evaluate it. While the angiogram will reveal the blockage, the treatment goal is to restore perfusion to the affected area of the heart through procedures such as balloon angioplasty or stent placement.

D) Prevent extensive myocardial damage:
This is the correct answer. The main goal of treatment for STEMI is to prevent extensive myocardial damage. In a STEMI, the coronary artery is blocked, depriving the heart muscle of oxygen, which can cause significant damage or death of the myocardial tissue. The most effective way to limit the extent of damage is to restore blood flow as quickly as possible, often through emergent procedures like percutaneous coronary intervention (PCI) or fibrinolytic therapy.

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Correct Answer is B

Explanation

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.

A. prevent the drainage by applying a tight pressure dressing B. administer antibiotics due to increased risk of infection C. allow fluid to drain from the patient's car onto gauze and notify D. hang intravenous (IV) fluids to replace fluids lost and prevent dehydration

Correct Answer is C

Explanation

A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.

B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.

C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.

D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.

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A client admitted to the Emergency Department with a suspected STEM. The nurse anticipates that this client will be immediately prepared for the cardiac catheterization laboratory as the goal of treatment is to:

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

Correct Answer is C

Explanation

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