The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:
reduce the risk of blood vessel spasm.
prevent platelet aggregation.
dissolve the blood clot.
prevent infection in the brain.
The Correct Answer is C
A. While blood vessel spasms can occur after a stroke, t-PA does not directly affect them.
B. Platelet aggregation is the process by which platelets stick together to form a clot. t-PA dissolves clots, but it does not prevent their formation.
C. Tissue plasminogen activator (t-PA) is a medication that can dissolve blood clots. In the case of a thrombotic stroke, a blood clot has blocked blood flow to the brain. By dissolving the clot, t-PA can restore blood flow and limit brain damage.
D. t-PA does not have any direct effect on the risk of infection in the brain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An ischemic stroke occurs when a blood vessel supplying blood to the brain is obstructed. Common symptoms include sudden numbness or weakness in the face, arm, or leg, confusion, difficulty speaking, and visual disturbances. However, "thunderclap" headache and neck stiffness are not typical symptoms of an ischemic stroke.
B. A TIA, often referred to as a "mini-stroke," produces similar symptoms to a stroke but lasts for a short duration (typically less than 24 hours) and does not cause permanent damage. Symptoms can include weakness, speech difficulties, and visual changes, but again, "thunderclap" headache and neck stiffness are not characteristic of a TIA.
C. A subarachnoid hemorrhage occurs when there is bleeding into the space between the brain and the tissues covering it, often due to a ruptured aneurysm. A "thunderclap" headache, described as an extremely sudden and severe headache, is a hallmark of this condition.
D. A cardioembolic stroke is a type of ischemic stroke that occurs when a blood clot forms in the heart and travels to the brain. Symptoms are similar to those of an ischemic stroke and do not typically include a "thunderclap" headache or neck stiffness.
Correct Answer is A
Explanation
A. Petechiae (small red or purple spots caused by bleeding under the skin) and epistaxis (nosebleeds) result from thrombocytopenia, which is a low platelet count often seen in leukemia. The compromised bone marrow function leads to inadequate production of platelets, resulting in bleeding and bruising.
B. While generalized edema and rash can occur in various conditions, they are not specific to ALL and are not common initial findings. Edema might be seen in certain contexts (e.g., renal involvement or fluid overload), but it is not a hallmark of ALL.
C. Alopecia (hair loss) and pallor (paleness) can occur in clients undergoing chemotherapy for ALL, but they are not typically initial findings at the time of diagnosis. Pallor may result from anemia, which can develop as a consequence of the disease, but it is not the most immediate or characteristic symptom of ALL.
D. Bradycardia (slow heart rate) and lethargy are not typical initial findings of ALL. Lethargy could be present due to anemia or other systemic effects, but bradycardia is not commonly associated with the disease and would require further investigation for other underlying causes.
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