The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

Risk for injury related to effects of thrombolysis.

Activity intolerance related to ischemia.

Ineffective breathing pattern related to adverse drug effects.

Deficient knowledge related to a new medication regimen.

Answer and Explanation

The Correct Answer is A

A. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.
B. While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.
C. While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.
D. Education about the new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period.

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Correct Answer is A

Explanation

A. This choice involves culturing a sputum sample collected from the patient to identify the presence of Mycobacterium tuberculosis, the bacterium that causes tuberculosis. A positive result confirms the diagnosis of TB.
B. Hemoccult tests are used to detect hidden (occult) blood in stool samples. While hemoptysis (coughing up blood) can be a symptom of TB, a hemoccult test is not specific for TB diagnosis. It is more commonly used in detecting gastrointestinal bleeding.
C. Imaging studies like chest x-ray or CT scans can reveal abnormalities in the lungs suggestive of TB, such as infiltrates, cavitations, or lymph node enlargement. While these tests can support the diagnosis, they are not definitive on their own.
D. The PPD skin test is a common screening tool for TB exposure. It detects the presence of a delayed hypersensitivity reaction to proteins derived from Mycobacterium tuberculosis. A positive PPD indicates exposure to TB but does not confirm active disease.

A. Meningococcal meningitis. B. Cerebrovascular accident (CVA). C. Intracerebral hemorrhage. D. Rocky mountain spotted fever.

Correct Answer is A

Explanation

A. Meningococcal meningitis is a bacterial infection of the meninges (the protective membranes covering the brain and spinal cord) caused by the bacterium Neisseria meningitidis. It is characterized by symptoms such as severe headache, fever, nuchal rigidity (stiff neck), and a petechial rash on the skin. The petechial rash is a distinguishing feature of meningococcal meningitis and is caused by bleeding into the skin due to disseminated intravascular coagulation (DIC) associated with the infection.
B. A cerebrovascular accident, commonly known as a stroke, occurs when blood flow to a part of the brain is interrupted, leading to tissue damage and neurological deficits. While a stroke can cause symptoms such as headache and neurological deficits, it typically does not present with fever, nuchal rigidity, or a petechial rash.

C. Intracerebral hemorrhage is bleeding within the brain tissue, often due to the rupture of a blood vessel. It can cause symptoms such as headache, neurological deficits, and alterations in consciousness, but it typically does not present with fever, nuchal rigidity, or a petechial rash.
D. Rocky mountain spotted fever (RMSF) is a bacterial infection caused by the bacterium. While RMSF can present with fever and rash, it typically does not present with nuchal rigidity, and the petechial rash associated with RMSF tends to start on the extremities rather than the arms and legs.

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The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Correct Answer is A

Explanation

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

Correct Answer is A

Explanation

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