A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

Current anticoagulant use

Blood pressure of 160/85 mm Hg

Complete neurologic assessment

Current treatment for client's peptic ulcer disease

Answer and Explanation

The Correct Answer is A

A. Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
B. While blood pressure is important to monitor, it is secondary to assessing anticoagulant use since high blood pressure alone does not contraindicate t-PA administration.
C. A complete neurologic assessment is important for determining the extent of the stroke but is not the immediate priority before administering t-PA.
D. While treatment for peptic ulcer disease is relevant, it is not directly related to the immediate risk factors for t-PA administration compared to anticoagulant use.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Sodium level: The client's sodium level is significantly elevated (157 mEq/L), indicating hyponatremia. This is a critical finding that needs to be addressed promptly to prevent serious complications such as seizures and coma.

Heart rate: While the heart rate is slightly elevated, it is not as urgent a concern as the sodium level. Once the sodium level is stabilized, the nurse can address the heart rate if it remains elevated.

A. Darken the client's room and close the door. B. Increase fluid intake. C. Administer naproxen sodium. D. Elevate the head of the bed to 30°.

Correct Answer is B

Explanation

A. Darkening the room can help reduce light sensitivity, but it does not address the underlying cause of the headache.
B. Increasing fluid intake is effective in managing a headache after a lumbar puncture because it helps replenish cerebrospinal fluid (CSF) and reduces the risk of post-lumbar puncture headache, which often results from CSF leakage.
C. Naproxen sodium can provide relief for headache pain, but increasing fluid intake addresses the root cause of the headache more directly.
D. Elevating the head of the bed is generally recommended for certain conditions, but it is not the most effective strategy for addressing a post-lumbar puncture headache, which is better managed by increasing fluid intake.

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A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 58-year-old client admitted with reports of increased urination and thirst. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's dropdown followed by the client's dropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Correct Answer is B

Explanation

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A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

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