A few days after a Cerebral Vascular Accident, the patient's family asks the nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response based on the knowledge that this drug must be used within:
4 hours
1 hour
24 hours
8 hours
The Correct Answer is A
A. 4 hours:
This option indicates that tissue plasminogen activator (tPA) must be administered within 4 hours of the onset of stroke symptoms to be considered as a drug therapy option. tPA is a thrombolytic medication used to dissolve blood clots in ischemic stroke, and its effectiveness is highest when administered promptly after the onset of symptoms.
B. 1 hour:
Administering tPA within 1 hour of stroke onset would be extremely challenging and impractical. It typically takes time for patients to recognize stroke symptoms, seek medical attention, and undergo diagnostic evaluations before tPA administration. While time is of the essence in stroke treatment, 1 hour is too short of a timeframe for most patients to receive tPA.
C. 24 hours:
Administering tPA beyond 4.5 hours of stroke onset is generally contraindicated due to the increased risk of complications, including hemorrhagic transformation of the stroke. While there may be some extended time windows considered for certain patients under specific circumstances, such as those meeting eligibility criteria for extended thrombolytic therapy, 24 hours is outside the standard timeframe for tPA administration.
D. 8 hours:
While tPA administration within 8 hours of stroke onset may be feasible for some patients, it is beyond the standard recommended time window for optimal effectiveness. As mentioned earlier, tPA is most effective when administered within the first 3 to 4.5 hours after the onset of symptoms, with earlier administration associated with better outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Placing padding around or under the patient's head
This is a helpful instruction to include. Placing padding around or under the patient's head can help prevent injury during a seizure by cushioning the head against impact with the ground.
B. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain
This is a correct instruction. Positioning the patient on their side (recovery position) can help prevent aspiration if vomiting occurs during or after the seizure. It also helps clear oral secretions and maintain a clear airway.
C. Having the necessary equipment and/or personnel in case the patient doesn't spontaneously breathe when the seizure is over
This is an important instruction. It is crucial to have emergency equipment (such as oxygen and suction) readily available and to be prepared to provide respiratory support if the patient does not spontaneously breathe after the seizure.
D. Inserting a tongue depressor in the patient's mouth
This is an incorrect instruction. It is not recommended to insert anything into the patient's mouth during a seizure as it can cause injury to the teeth, gums, or airway. Additionally, it is a common misconception that tongue swallowing occurs during seizures, which is rare.
E. Noting the time the seizure started
This is a critical instruction. Noting the time the seizure started helps healthcare providers assess the duration of the seizure and determine if medical intervention is necessary. It also helps monitor the patient's recovery and response to treatment.
F. Holding the patient down to prevent injury
This is an incorrect instruction. Holding the patient down during a seizure can cause injury to both the patient and the person restraining them. It is important to create a safe environment by removing hazards and guiding the patient away from dangerous objects or situations, but holding them down is not appropriate.
Correct Answer is C
Explanation
A. Lhermitte's sign:
Lhermitte's sign is a neurological symptom characterized by a sensation of electric shock-like pain that radiates down the spine and into the limbs, typically triggered by flexing the neck forward. It is often described as shooting or stabbing pain and is commonly associated with lesions or damage to the cervical spinal cord. Lhermitte's sign is not associated with a tightening sensation around the torso but rather with shooting pain down the spine and limbs.
B. Trigeminal neuralgia:
Trigeminal neuralgia is a neurological condition characterized by severe, shooting pain along the trigeminal nerve, which supplies sensation to the face. The pain is typically triggered by activities such as chewing, speaking, or touching the face. Trigeminal neuralgia causes sudden, intense, electric shock-like pain in the face, particularly in the areas supplied by the trigeminal nerve (e.g., cheek, jaw, forehead). It is not associated with a tightening sensation around the torso.
C. MS hug:
The "MS hug" is a symptom experienced by some individuals with multiple sclerosis, characterized by a sensation of tightness, pressure, or squeezing around the chest, abdomen, or torso. It can feel like a band tightening around the body and may be described as a constricting or girdling sensation. The MS hug is caused by spasms or tightening of the muscles surrounding the rib cage or the intercostal muscles due to damage to the nerves that control muscle function in MS.
D. Paroxysmal spasms:
Paroxysmal spasms refer to sudden, involuntary muscle contractions or spasms that occur intermittently. These spasms can affect various parts of the body and are commonly associated with conditions like multiple sclerosis. However, they typically present as brief, sudden contractions rather than a persistent tightening sensation around the torso.
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