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 A

Explanation

A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is crucial for managing SLE and preventing flare-ups. This demonstrates the client's understanding of the importance of medication adherence.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is known to exacerbate SLE. This statement reflects an understanding of the need to reduce stress to manage the disease effectively.
D. Wearing protective clothing when going outside is essential to prevent sun exposure, which can trigger SLE flare-ups. This indicates that the client understands the need for sun protection.

A. Osteoarthritis B. Place of employment C. Gentamycin D. Naproxen E. Bumetanide F. Heart failure

Correct Answer is ["B","C","D","E"]

Explanation

A. Osteoarthritis is not associated with hearing loss
B. The client's place of employment as a firearms instructor at a shooting range exposes them to loud noises, which is a well-known risk factor for hearing loss.
C. Gentamycin is an aminoglycoside antibiotic that can be ototoxic, especially when administered in high doses or for prolonged periods, potentially leading to hearing loss.
D. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that has been associated with an increased risk of hearing loss, particularly when taken regularly or in high doses.
E. Bumetanide is a loop diuretic that can also have ototoxic effects, especially when used in conjunction with aminoglycoside antibiotics like gentamycin.
F. Heart failure is not associated with hearing loss

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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

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Correct Answer is A

Explanation

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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?