A nurse is caring for a client who has had a stroke.

Exhibits

Select the 3 findings that require immediate follow-up.

Drooling

Blood pressure at 1800

Breath sounds at 1000

Hoarse voice

Temperature at 1800

Answer and Explanation

Correct Answer : A,D,E

A. Drooling
Drooling can be concerning due to impaired swallowing and risk of aspiration.
D. Hoarse voice
Hoarseness after swallowing can indicate aspiration, which is a serious complication for stroke patients due to difficulty swallowing.
E. Temperature at 1800
A temperature of 39.6°C (103.3°F) is significantly elevated and suggests a potential infection, which is a serious complication after a stroke

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Correct Answer is B

Explanation

A. While there are strict inclusion and exclusion criteria for alteplase administration, this statement is overly broad. There are certain situations where anticoagulant or antiplatelet therapy can be managed to allow for alteplase use.
B. Alteplase is administered as a bolus over 1 minute, followed by an infusion over 60 minutes.
C. While time is critical in stroke treatment, the recommended window for alteplase administration is typically within 3-4.5 hours of symptom onset.
D. The maximum dose of alteplase is actually 0.9 mg/kg, up to a maximum of 90 mg.

A. Heart rate 160/min B. Hypokalemia C. Mottled skin D. Blood pressure 115/68 mmHg

Correct Answer is A

Explanation

A. Tachycardia is a classic sign of the compensatory stage of shock. The body attempts to increase cardiac output by increasing heart rate to maintain blood pressure.
B. Hypokalemia is more likely to occur in the later stages of shock, as it's associated with tissue breakdown and renal dysfunction.
C. Mottled skin is a sign of the progressive stage of shock, indicating poor peripheral perfusion.
D. Blood pressure 115/68 mmHg: While this might be considered within normal range, it's important to consider the baseline blood pressure of the patient. In the compensatory stage, blood pressure may be maintained, but there are other compensatory mechanisms in place (like increased heart rate) to do so.

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A nurse is caring for a client who has had a stroke. Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The emergency department nurse is preparing an infusion of IV alteplase for a client who suffered a cerebrovascular accident (CVA). Which of the following statements is accurate about the administration of alteplase?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

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A nurse is caring for a client who has had a stroke.

Exhibits

Select the 3 findings that require immediate follow-up.