The nurse is caring for client who has had a stroke and who has received tissue plasminogen activator (t-PA) 4 hours ago in the emergency department. During the nurse's initial assessment, which of the following signs and symptoms are indications of a complication post thrombolytic therapy? (SELECT ALL THAT APPLY)

Fever and Cardiac dysrhythmias

Elevated BP & patient reports headache

Positive Babinski’s sign

Patient has vomited once and reports nausea

decreased level of consciousness

Answer and Explanation

Correct Answer : B,D,E

A. Fever and cardiac dysrhythmias are not specific complications of tissue plasminogen activator (t-PA) therapy. While they can occur after a stroke or as a general response to illness, they are not the primary indicators of complications related to thrombolytic therapy.

B. An elevated blood pressure combined with a headache could indicate a hemorrhagic transformation, which is a serious complication after t-PA administration. Thrombolytic therapy increases the risk of bleeding, and these symptoms may signal intracranial hemorrhage.

C. A positive Babinski's sign (extensor plantar response) is often seen in stroke patients as a neurological finding, but it is not specifically an indication of a complication from t-PA therapy. It is more reflective of the brain injury or stroke itself rather than the medication.

D. Nausea and vomiting can be signs of increased intracranial pressure (ICP), which could result from hemorrhage following t-PA therapy. This is a critical sign that requires immediate evaluation to rule out complications such as bleeding.

E. A decreased level of consciousness is a significant red flag and may indicate cerebral hemorrhage or another serious complication related to the administration of t-PA. Monitoring for changes in neurological status is crucial following thrombolytic therapy.

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Correct Answer is C

Explanation

A. Diarrhea is not a typical symptom of Parkinson’s disease. Parkinson’s disease can cause constipation due to decreased gastrointestinal motility.
B. Hypertension is not a hallmark feature of Parkinson’s disease. In fact, patients may experience orthostatic hypotension (a drop in blood pressure when standing) due to autonomic dysfunction.
C. Muscle rigidity is a common symptom of Parkinson's disease. It refers to stiffness or inflexibility of muscles, which can cause difficulty with movement.
D. Facial pain is not a typical symptom of Parkinson’s disease. While people with PD may develop a reduced facial expression (mask-like face), it does not generally cause pain.

A. contacts a support group for tobacco cessation B. makes an appointment with his primary care provider as soon as possible. C. avoid highly seasoned or acidic foods while to wound is actively oozing. D. goes to an urgent care center to have his coagulation studies checked (PT/APTT/INR)

Correct Answer is B

Explanation

A. While tobacco cessation is important for overall health, the priority in this case is addressing the potentially serious issue of a persistent sore that has been oozing blood for a month. This could be indicative of oral cancer, particularly given the client's long history of tobacco use.
B. Making an appointment with his primary care provider as soon as possible is the most appropriate recommendation. A persistent, non-healing lesion, especially with bleeding, should be evaluated by a healthcare provider to rule out oral cancer or other serious conditions. Early detection and intervention are crucial.
C. While avoiding highly seasoned or acidic foods while the wound is actively oozing might help reduce irritation to the sore, it does not address the underlying concern of the potential cancerous lesion that needs to be evaluated by a healthcare provider.
D. Going to an urgent care center to have his coagulation studies checked is no indication that the client has a bleeding disorder, so checking coagulation studies is not the immediate priority. The focus should be on evaluating the sore for signs of cancer or other serious conditions.

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Naxlex Comprehensive Predictor Exams

The nurse assessing the client diagnosed with Parkinson's disease (PD) would expect which of the following assessment findings?

Correct Answer is C

Explanation

A 53-year-old works as a roofer & has chewed tobacco for 35 years. He tells the occupational health nurse that he has had a sore on his lip that been oozing blood for the past month. It is essential that the nurse recommends he;

Correct Answer is B

Explanation

A nurse knows that the liver is a common site for metastasis from other primary cancers due to:

A nurse is educating a client about a recent diagnosis of pancreatic cancer. Which of the following information should the nurse include in the client education?

The nurse is caring for a client with an acute head injury. Which assessment finding would first alert the nurse that the client is developing an Increase in intracranial pressure?

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?

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