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 B

Explanation

A. Urticaria (hives) is not a common side effect of radiation therapy. The skin should be examined for localized radiation-induced skin changes, such as erythema or dryness, rather than generalized urticaria.
B. Radiation therapy can weaken the immune system, increasing the risk of infection. The nurse should monitor for signs of infection, especially in areas affected by radiation, as the skin and mucous membranes can become more vulnerable.
C. Low hemoglobin is not a direct or immediate concern related to radiation therapy for lung cancer. However, it could occur if the patient experiences bone marrow suppression, but this is not typically the primary concern for radiation therapy to the lung.
D. Xerostomia (dry mouth) is more commonly associated with radiation therapy to the head and neck area. Radiation to the lungs generally does not affect salivary glands, so monitoring for xerostomia is not necessary in this case.

A. Pancreatic cancers are classified as either endocrine pancreatic cancer or exocrine pancreatic cancer. B. Pancreatic cancer typically develops from a polyp C. The pancreas location increases the risk that cancer will spread into nearby structures and blood vessels D. Pancreatic Cancer is distinguished based on the layers of the pancreas.

Correct Answer is C

Explanation

A. The subdivision of pancreatic tumors into endocrine versus exocrine reflects their cell of origin (islet cells versus ductal cells) rather than conveying information about how the cancer behaves in situ or its propensity for local invasion and metastasis

B. Unlike some other cancers (e.g., colorectal cancer), pancreatic cancer does not typically develop from polyps. Most cases of pancreatic cancer develop from the pancreatic ductal cells (the cells lining the ducts of the pancreas), and the disease is typically aggressive and diagnosed at a later stage.

C. Because the pancreas lies deep in the retroperitoneum directly adjacent to major vessels like the superior mesenteric artery and portal vein, tumors often extend into these structures early, contributing to the high rate of advanced disease at diagnosis

D. Pancreatic cancer is not distinguished based on layers. Instead, it is generally categorized based on the type of cells it affects (e.g., ductal cells in exocrine pancreatic cancer). The staging of pancreatic cancer is based on factors like tumor size, lymph node involvement, and metastasis, rather than the layers of the pancreas.

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Naxlex Comprehensive Predictor Exams

nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure?

The nurse is assessing a client for the risk of developing skin cancer. It would be a priority for the nurse to suggest follow up for which client?

A nurse is developing an education program about skin cancer for a community center. Which of the following instructions should the nurse plan to include?

Which assessment finding requires an immediate intervention by the nurse for the patient after surgery for the treatment of gastric cancer?

A nurse is caring for a client who has colorectal cancer and is recovering from surgery to redirect intestinal contents out of the body. Which of the following post-surgical manifestations require nursing intervention to avoid a serious complication?

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

The nurse is caring for a client with Meniere's disease. What will the nurse recommend for the client to do to reduce symptoms of vertigo?

The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The nurse recognizes that which laboratory test order set will most effectively guide the provider to a diagnosis of DIC?