The assessment that indicates a fluid volume excess in a patient in the acute phase of a CVA is:

adventitious breath sounds

weak pulse

hypotension

poor skin turgor

Answer and Explanation

The Correct Answer is A

A. Adventitious breath sounds:

Adventitious breath sounds refer to abnormal lung sounds heard upon auscultation of the chest. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. In the context of fluid volume excess, particularly in the acute phase of a cerebrovascular accident (CVA) or stroke, adventitious breath sounds such as crackles are indicative of pulmonary edema. Pulmonary edema occurs when there is an excessive accumulation of fluid in the lungs, impairing gas exchange and leading to symptoms such as shortness of breath and respiratory distress.

B. Weak pulse:

A weak pulse may suggest poor perfusion or decreased cardiac output rather than fluid volume excess. While decreased cardiac output can be a consequence of heart failure, which may be associated with fluid volume excess, a weak pulse is not a direct indicator of fluid overload. In the acute phase of a CVA, a weak pulse may prompt further assessment for other cardiovascular complications or neurogenic shock.

C. Hypotension:

Hypotension, or low blood pressure, is not typically associated with fluid volume excess. Instead, hypotension may indicate hypovolemia, shock, or other underlying cardiovascular conditions. While hypotension can occur secondary to severe heart failure or fluid overload in some cases, it is not a direct indicator of fluid volume excess in the acute phase of a CVA.

D. Poor skin turgor:

Poor skin turgor is a clinical finding associated with dehydration rather than fluid volume excess. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. In contrast, fluid volume excess is characterized by edema, which may manifest as pitting or non-pitting edema, rather than poor skin turgor. However, in fluid volume excess, the skin may appear stretched or taut due to the accumulation of fluid in the interstitial spaces.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Check the client for a fecal impaction.

This intervention is important for managing autonomic dysreflexia because a fecal impaction can trigger autonomic dysreflexia by causing rectal distention. However, it is not the first action the nurse should take. Promptly addressing the immediate cause of autonomic dysreflexia is crucial to prevent complications.

B. Ensure the room temperature is warm.

This intervention is important for maintaining the client's comfort and preventing temperature-related complications. However, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Immediate interventions to address the underlying cause of autonomic dysreflexia are necessary to prevent serious complications such as stroke or seizure.

C. Check the client's bladder for distention.

This is the correct action to take first. Bladder distention is one of the most common triggers of autonomic dysreflexia in individuals with spinal cord injuries. A distended bladder stimulates autonomic reflexes, leading to a sudden increase in blood pressure. Therefore, the nurse should assess the client's bladder for distention and initiate appropriate interventions such as catheterization to relieve urinary retention.

D. Raise the head of the bed.

While elevating the head of the bed can help reduce blood pressure in some situations, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Elevating the head of the bed may exacerbate autonomic dysreflexia by increasing venous return and blood pressure. Therefore, addressing the underlying cause of autonomic dysreflexia, such as bladder distention, takes priority.

A. 4 hours B. 1 hour C. 24 hours D. 8 hours

Correct Answer is A

Explanation

A. 4 hours:

This option indicates that tissue plasminogen activator (tPA) must be administered within 4 hours of the onset of stroke symptoms to be considered as a drug therapy option. tPA is a thrombolytic medication used to dissolve blood clots in ischemic stroke, and its effectiveness is highest when administered promptly after the onset of symptoms.

B. 1 hour:

Administering tPA within 1 hour of stroke onset would be extremely challenging and impractical. It typically takes time for patients to recognize stroke symptoms, seek medical attention, and undergo diagnostic evaluations before tPA administration. While time is of the essence in stroke treatment, 1 hour is too short of a timeframe for most patients to receive tPA.

C. 24 hours:

Administering tPA beyond 4.5 hours of stroke onset is generally contraindicated due to the increased risk of complications, including hemorrhagic transformation of the stroke. While there may be some extended time windows considered for certain patients under specific circumstances, such as those meeting eligibility criteria for extended thrombolytic therapy, 24 hours is outside the standard timeframe for tPA administration.

D. 8 hours:

While tPA administration within 8 hours of stroke onset may be feasible for some patients, it is beyond the standard recommended time window for optimal effectiveness. As mentioned earlier, tPA is most effective when administered within the first 3 to 4.5 hours after the onset of symptoms, with earlier administration associated with better outcomes.

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The assessment that indicates a fluid volume excess in a patient in the acute phase of a CVA is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A few days after a Cerebral Vascular Accident, the patient's family asks the nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response based on the knowledge that this drug must be used within:

Correct Answer is A

Explanation

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