A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question?
Start a labetalol drip to keep BP less than 140/90 mm Hg.
Keep the head of the bed elevated at least 30 degrees.
Begin tissue plasminogen activator (tPA) intravenously per protocol.
Infuse normal saline intravenously at 75 mL/hr.
The Correct Answer is C
A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.
B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.
C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.
D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The patient reports having a stiff neck: While a stiff neck may indicate meningeal irritation, which can be associated with a subarachnoid hemorrhage, it is not as immediately concerning as hypotension, which can indicate hypovolemic shock or complications such as vasospasm.
B. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs): The presence of red blood cells in the cerebrospinal fluid is expected in a subarachnoid hemorrhage and is an important diagnostic finding but may not require immediate intervention.
C. The patient reports a severe and unrelenting headache: While a severe and unrelenting headache is a common symptom of subarachnoid hemorrhage, it is not as urgent as addressing hypotension, which can indicate hemodynamic instability and compromise perfusion to vital organs.
D. The patient's blood pressure (BP) is 90/50 mm Hg: Hypotension in a patient with a subarachnoid hemorrhage can indicate hypovolemic shock, vasospasm, or other complications. It is important to communicate this finding promptly to the healthcare provider for further
evaluation and management.
Correct Answer is A
Explanation
A. Paraplegia: Paraplegia is the paralysis of the lower extremities and possibly the trunk, which can occur with a spinal cord injury at the level of the T2-T3 vertebrae.
B. Paresthesia: Paresthesia refers to abnormal sensations such as tingling or numbness and is not typically associated with a spinal cord injury at the T2-T3 level. It may occur with nerve damage but is not the primary disability anticipated in this scenario.
C. Quadriplegia: Quadriplegia, also known as tetraplegia, involves paralysis of all four limbs and the trunk. It is more commonly associated with injuries at higher levels of the spinal cord, such as cervical injuries.
D. Hemiplegia: Hemiplegia involves paralysis of one side of the body and is typically caused by a stroke or brain injury, not a spinal cord injury at the T2-T3 level.
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