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 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. It raises cardiac output and MAP. B. It causes vasoconstriction and increased MAP. C. There is no direct correlation to MAP. D. Lower blood volume lowers MAP.

Correct Answer is D

Explanation

A. Severe blood loss actually decreases blood volume, which leads to decreased cardiac output and ultimately lower MAP.
B. While it's true that the body initially responds to blood loss by vasoconstricting to maintain blood pressure, this compensatory mechanism can only last for so long. As blood loss continues, MAP will decrease.
C. There is no direct correlation to MAP. MAP is directly influenced by cardiac output and systemic vascular resistance (SVR). Blood volume is a major determinant of both.
D. A decrease in blood volume leads to decreased preload, which reduces cardiac output. This, in turn, lowers MAP.

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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

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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Correct Answer is D

Explanation

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