A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

Spinal cord degeneration

Decorticate posturing

Atypical hyperreflexia

Decerebrate posturing

Answer and Explanation

The Correct Answer is D

A.   Spinal cord degeneration is a general term for the deterioration of the spinal cord and doesn't specifically describe the patient's posture.
B.   Decorticate posturing is characterized by the arms flexed and adducted, with the wrists and fingers flexed. The legs are extended and adducted, with the feet plantar flexed.
C.   Atypical hyperreflexia refers to exaggerated reflexes, not a specific posture.

D.   Decerebrate posturing is characterized by the arms extended and pronated, with the wrists and fingers flexed. The legs are stiffly extended with plantar flexion.

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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.

A. The drug is not given to clients who are taking anticoagulant or antiplatelet therapy. B. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. C. The recommended time for drug administration is within 90 minutes after admission to the emergency department. D. The maximum dosage of the drug, including the bolus, is 120 mg intravenously.

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.

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A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

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Naxlex Comprehensive Predictor Exams

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

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

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