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 ["15"]
Explanation
To calculate the dose of amantadine for a client with parkinsonism, the nurse needs to use the following formula:
Dose (mL) = Ordered dose (mg) / Concentration (mg/mL).
In this case, the ordered dose is 150 mg and the concentration is 50 mg/5 mL. Therefore, the dose in mL is:
Dose (mL) = 150 mg / (50 mg/5 mL)
Dose (mL) = 150 mg x (5 mL/50 mg)
Dose (mL) = 15 mL
The nurse should round the answer to the nearest whole number, which is 15 mL. The nurse should administer 15 mL of amantadine oral solution to the client.
Correct Answer is B
Explanation
A. "Have you had an MMR immunization?"
This question is not directly relevant to the assessment of Guillain-Barré syndrome. MMR immunization history may be pertinent to other health assessments, such as immunity to measles, mumps, and rubella.
B. "Have you had a recent upper respiratory infection?"
This is the correct answer. GBS often occurs after a recent upper respiratory or gastrointestinal infection, so asking about recent illnesses can provide valuable information for diagnosis.
C. "Have you traveled overseas recently?"
While travel history may be relevant to certain infectious diseases, it is not typically associated with the development of Guillain-Barré syndrome. Therefore, this question is less pertinent in this context.
D. "Are you taking a multivitamin?"
The use of multivitamins is unlikely to be directly related to the development of Guillain-Barré syndrome. While nutritional status is important for overall health, it is not a primary focus when assessing for GBS.
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