A nurse in an emergency department is caring for a client who has manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take?

Initiate fibrinolytic therapy.

Place the client in a supine position.

Prepare the client for a chest x-ray.

Insert an indwelling urinary catheter.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Initiate fibrinolytic therapy: Fibrinolytic therapy, such as tissue plasminogen activator (tPA), is most effective when administered within a 3- to 4.5-hour window from the onset of ischemic stroke symptoms. Early administration can dissolve the clot, restore cerebral blood flow, and improve neurological outcomes.

B. Place the client in a supine position: Clients with ischemic stroke are usually positioned with the head of the bed elevated 15–30 degrees unless contraindicated. Supine positioning can increase intracranial pressure and risk aspiration, which may worsen neurological status.

C. Prepare the client for a chest x-ray: A chest x-ray is not a priority in acute ischemic stroke management. Immediate neuroimaging, typically a CT scan, is required to differentiate ischemic from hemorrhagic stroke before initiating fibrinolytic therapy.

D. Insert an indwelling urinary catheter: Inserting a catheter is not indicated as an initial intervention for acute stroke unless the client is unable to void or requires strict output monitoring. Priority actions focus on neuroprotection and reperfusion therapy.

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Correct Answer is D

Explanation

Rationale:
A. "Your child can return to school 24 hours after beginning antibiotics.": Varicella (chickenpox) is a viral infection, so antibiotics are not effective unless there is a secondary bacterial infection.

B. "Your child can return to school once the fever has subsided.": Although the fever may resolve, the child remains contagious until all lesions have crusted over, so returning at this stage risks spreading infection.

C. "Your child can return to school after a negative titer result.": Titer testing is used to assess immunity, not for determining when an active infection is no longer contagious.

D. "Your child can return to school once the lesions have crusted over.": This is the correct statement because a child with varicella is contagious until all vesicular lesions have dried and crusted, usually about 5–7 days after onset.

A. "I will plan to continue taking this medication for at least 5 years." B. "My provider wants me to take this medication for 2 weeks before I try to quit drinking." C. "I should avoid over-the-counter medications that contain alcohol." D. "I will need to get a monthly injection of this medication."

Correct Answer is C

Explanation

Rationale:
A. "I will plan to continue taking this medication for at least 5 years.": Disulfiram therapy is not prescribed for a fixed duration such as 5 years. The length of treatment depends on the client’s motivation and response, typically continuing until long-term abstinence is maintained.

B. "My provider wants me to take this medication for 2 weeks before I try to quit drinking.": Disulfiram must be started only after the client has abstained from alcohol for at least 12 hours, not before quitting. Taking it while alcohol is still in the system can trigger severe reactions such as flushing, nausea, vomiting, and hypotension.

C. "I should avoid over-the-counter medications that contain alcohol.": Even small amounts of alcohol—such as in cough syrups, mouthwash, or sauces—can cause a dangerous disulfiram-alcohol reaction. Clients must avoid all alcohol-containing products.

D. "I will need to get a monthly injection of this medication.": Disulfiram is taken orally, usually once daily, and does not come in injectable form. The injectable medication used for alcohol dependence is naltrexone (Vivitrol).

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A nurse in an emergency department is caring for a client who has manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take?

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