The nurse assesses a client with disseminated intravascular coagulation who is being treated with blood products and heparin.
Which cues indicate worsening organ dysfunction and continued bleeding? Select all that apply.

Acute stroke management requires rapid application of the time-is-brain principle. Knowledge of the differential diagnosis between ischemic and hemorrhagic strokes is vital. Practitioners must prioritize diagnostic imaging that safely identifies hemorrhage to determine if thrombolytic therapy is indicated.

Choice A rationale

A non-contrast CT scan is the gold standard for initial stroke assessment to rule out intracranial hemorrhage. It is faster than an MRI and avoids contrast, which can mimic blood or cause kidney injury in emergencies.

Choice B rationale

Contrast is avoided during the initial emergency scan because it can leak into brain tissue and appear hyperdense. This mimics the appearance of acute blood, making it difficult to distinguish between a bleed and ischemia.

Choice C rationale

Thrombolytics cannot be administered until a CT scan confirms the absence of a hemorrhage. Giving these drugs to a patient with a brain bleed would cause catastrophic worsening of the condition and potential death.

Choice D rationale

While IV access and hydration are important, they are secondary to identifying the type of stroke. Diagnostic imaging must occur first to facilitate the most time-sensitive treatments like fibrinolysis or mechanical thrombectomy for ischemia.

This case involves phenytoin toxicity resulting from a level exceeding the therapeutic range of 10 to 20 mg/dL. Knowledge of central nervous system effects, pharmacokinetics, and toxicological manifestations of anticonvulsants is necessary to identify appropriate neurological assessment findings.

Choice A rationale

Nystagmus, or involuntary eye movement, is a classic sign of phenytoin toxicity as levels rise above 20 mg/dL. It results from the drug's effect on the cerebellum and vestibular system, disrupting normal extraocular muscle coordination and balance.

Choice B rationale

Phenytoin typically causes hyperglycemia rather than hypoglycemia because it inhibits insulin secretion. A serum level of 32 mg/dL would not be expected to lower blood glucose; monitoring for elevated glucose levels is more appropriate in toxicity.

Choice C rationale

Ataxia involves uncoordinated muscle movements and gait instability, frequently occurring when phenytoin levels exceed therapeutic limits. The drug affects cerebellar function, leading to significant motor impairment and increasing the client's risk for falls and physical injury.

Choice D rationale

Vertigo or dizziness is a common central nervous system side effect of high phenytoin concentrations. As the drug reaches toxic levels like 32 mg/dL, it interferes with vestibular signaling, causing the sensation of spinning or loss of balance.

Choice E rationale

Phenytoin toxicity is more likely to cause blood dyscrasias like leukopenia or thrombocytopenia rather than a high platelet level. Normal platelet counts are 150,000 to 400,000 cells/mm; high levels are not a recognized manifestation of phenytoin overdose.