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. Cholelithiasis (gallstones) is a known risk factor for acute pancreatitis, as gallstones can block the bile duct and lead to inflammation of the pancreas.
B. Addison disease is not directly associated with an increased risk of acute pancreatitis. It primarily affects adrenal gland function.
C. Hypothyroidism does not typically influence the risk of developing acute pancreatitis. The condition primarily affects metabolism.
D. Gout is a condition related to elevated uric acid levels and is not a direct risk factor for acute pancreatitis.

A. A client who has a leg and ankle fracture B. A client who reports flank pain radiating to the groin C. A client who has a raised red rash on the abdomen D. A client who has expiratory stridor

Correct Answer is D

Explanation

A. A leg and ankle fracture is serious but typically not life-threatening compared to issues involving airway obstruction or severe bleeding.
B. Flank pain radiating to the groin may indicate a kidney stone or other condition, but it is less urgent than airway obstruction.
C. A raised red rash on the abdomen could be a sign of a less urgent condition, such as a viral infection or allergic reaction, and does not require immediate intervention compared to respiratory distress.
D. Expiratory stridor indicates upper airway obstruction or severe respiratory distress, which is a life-threatening condition requiring immediate intervention. Stridor suggests possible airway compromise, which needs to be addressed urgently to prevent respiratory failure.

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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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