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. Petechiae are small, red or purple spots on the skin that indicate bleeding under the skin and are a classic sign of thrombocytopenia, a condition characterized by a low platelet count.
B. A decreased white blood cell count is more indicative of leukopenia, not thrombocytopenia. Thrombocytopenia specifically affects platelet counts.
C. Increased fatigue can be a symptom of many conditions but is not specific to thrombocytopenia. It may occur due to anemia or other side effects of chemotherapy.
D. Unexplained bone pain is not a typical symptom of thrombocytopenia. It might be related to other conditions or side effects but is not specific to low platelet counts.

A. HbA1c level of 7.5% (nl. 4.4-6.4%) B. 2-hour post-prandial blood glucose level of 122 mg/dL (nl. <120 mg/dL) C. Random blood glucose level of 300 mg/dL (nl. <200 mg/dL) D. Fasting blood glucose level of 48 mg/dL (nl. 60-110 mg/dL)

Correct Answer is C

Explanation

A. An HbA1c level of 7.5% indicates suboptimal long-term glucose control. The target for many diabetic patients is usually below 7%, but it may not require immediate action compared to more acute indicators.
B. A 2-hour post-prandial blood glucose level of 122 mg/dL is slightly above the normal range but not significantly high. This result alone is not as indicative of inadequate control as other values.
C. A random blood glucose level of 300 mg/dL is significantly elevated and indicates poor glucose control. This value is much higher than the normal range and suggests a need for further teaching and adjustment of diabetes management.
D. A fasting blood glucose level of 48 mg/dL is low and could indicate hypoglycemia rather than inadequate control. This level requires immediate attention but does not reflect poor long-term diabetes management.

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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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