A nurse is caring for a client who has ischemic stroke and is receiving thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Which of the following actions should the nurse take? (Select all that apply.)

Monitor the client's vital signs and neurological status frequently.

Administer rtPA within 4.5 hours of symptom onset.

Maintain the client's systolic blood pressure below 180 mm Hg.

Give aspirin or other antiplatelet agents along with rtPA.

Assess the client for signs of bleeding or hemorrhagic transformation.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:
This is correct because monitoring the client's vital signs and neurological status frequently can help detect any changes in the client's condition, such as improvement or deterioration of symptoms, or complications such as bleeding or increased intracranial pressure.

Choice B reason:
This is correct because administering rtPA within 4.5 hours of symptom onset can increase the chances of restoring blood flow to the ischemic brain tissue and reducing neurological damage. The effectiveness and safety of rtPA decrease after this time window.

Choice C reason:
This is correct because maintaining the client's systolic blood pressure below 180 mm Hg can prevent further ischemia or hemorrhage in the brain. High blood pressure can increase the risk of bleeding or reperfusion injury after thrombolytic therapy.

Choice D reason:
This is incorrect because giving aspirin or other antiplatelet agents along with rtPA can increase the risk of bleeding or hemorrhagic transformation. Antiplatelet agents should be avoided for at least 24 hours after thrombolytic therapy.

Choice E reason:
This is correct because assessing the client for signs of bleeding or hemorrhagic transformation can help identify any adverse effects of thrombolytic therapy. Bleeding or hemorrhagic transformation can manifest as hematuria, hematemesis, melena, petechiae, ecchymosis, epistaxis, gingival bleeding, headache, altered mental status, or worsening neurological deficits.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:

This is a correct statement, as the PNS consists of cranial and spinal nerves that connect the CNS to the rest of the body and transmit sensory and motor signals.

Choice B reason:

This is a correct statement, as the PNS is divided into two subdivisions: the somatic nervous system (SNS) and the autonomic nervous system (ANS).

Choice C reason:

This is a correct statement, as the PNS controls voluntary movements of skeletal muscles and provides sensory feedback from the skin, joints, and muscles through the SNS.

Choice D reason:

This is an incorrect statement, as this is the function of the ANS, which is a subdivision of the PNS. The ANS regulates involuntary functions of smooth muscles, cardiac muscles, and glands through its two branches: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS).

A. Decreased sensation in the feet and lower legs. B. Increased muscle tone and reflexes in the upper limbs. C. Decreased pain perception in the hands and fingers. D. Increased sweating and flushing in the face and neck.

Correct Answer is A

Explanation

Choice A reason:

This is the correct answer because peripheral neuropathy affects the sensory nerves, which can cause loss of sensation, especially in the distal parts of the body. Diabetes mellitus is a common cause of peripheral neuropathy.

Choice B reason:

This is incorrect because peripheral neuropathy does not affect the motor nerves, which control muscle tone and reflexes. Increased muscle tone and reflexes in the upper limbs are more likely to indicate a central nervous system disorder, such as a stroke or spinal cord injury.

Choice C reason:

This is incorrect because peripheral neuropathy can cause decreased pain perception in any part of the body, not just the hands and fingers. However, this is not a specific finding for peripheral neuropathy, as other conditions can also impair pain perception, such as spinal cord injury or opioid use.

Choice D reason:

This is incorrect because peripheral neuropathy does not affect the autonomic nerves, which control sweating and flushing. Increased sweating and flushing in the face and neck are more likely to indicate a sympathetic nervous system disorder, such as pheochromocytoma or carcinoid syndrome.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has ischemic stroke and is receiving thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the anatomy of the peripheral nervous system (PNS) with a group of nursing students. Which of the following statements by a student indicates a need for further teaching?

Correct Answer is D

Explanation

A nurse is assessing a client who has peripheral neuropathy due to diabetes mellitus. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is evaluating the outcomes of a client who has ischemic stroke and has received rehabilitation. Which of the following statements by the client indicates an improvement in functional recovery?

A nurse is teaching a client about the functions of the central nervous system (CNS). Which of the following statements by the client indicates a need for further teaching?

A client has been diagnosed with radiculopathy due to a herniated disc in the lumbar spine. The nurse should instruct the client to avoid which of the following activities? (Select all that apply.)

A nurse is administering medication to a client who has Parkinson's disease. The client asks the nurse how the medication works. Which of the following responses by the nurse is appropriate?

A nurse is planning care for a client who has ischemic stroke and is at risk for cerebral edema. Which of the following interventions should the nurse include in the plan?

A nurse is teaching a client who has peripheral neuropathy about foot care. Which of the following statements by the client indicates an understanding of the teaching?