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 A

Explanation

Rationale:
A. Gently push the syringe plunger to administer medication: Medications given via NG tube should be administered slowly and gently using a syringe to avoid tube damage, aspiration, or sudden changes in gastric pressure. This technique ensures safe and effective delivery of the medication.

B. Dissolve the medications together: Mixing multiple medications can cause chemical interactions or precipitation, which can block the NG tube or reduce medication efficacy. Each medication should be dissolved and administered separately.

C. Flush the NG tube with 5 mL of cold tap water after administration: Flushing is necessary to maintain tube patency, but 5 mL is insufficient for continuous feedings. Typically, 15–30 mL of warm or room-temperature water is used to prevent tube occlusion.

D. Add medication directly to the enteral feeding: Adding medication to the feeding can alter the composition, affect absorption, and create a risk for tube blockage. Medications should be given separately with flushing before and after administration.

A. A client who has decreased urine cortisol levels B. A client who has decreased interleukin-6 levels C. A client who has decreased C-reactive protein levels D. A client who has decreased serotonin levels

Correct Answer is D

Explanation

Rationale:
A. A client who has decreased urine cortisol levels: Hypercortisolism or dysregulated cortisol is more commonly linked to depressive symptoms, so decreased levels would not indicate a primary need for antidepressant therapy.

B. A client who has decreased interleukin-6 levels: Interleukin-6 is an inflammatory marker, and elevated levels have been associated with depression. Decreased IL-6 does not indicate inflammation-related depression or a need for antidepressants.

C. A client who has decreased C-reactive protein levels: Low C-reactive protein indicates minimal systemic inflammation. Since elevated CRP can correlate with depressive states, decreased CRP does not identify a candidate for antidepressant therapy.

D. A client who has decreased serotonin levels: Reduced serotonin is linked to depressive disorders. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), aim to increase serotonin availability in the brain, making this client an appropriate candidate for therapy.

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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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