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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Free Nursing Study Resources

Correct Answer is ["66.7"]

Explanation

Step 1: Write down the formula
Rate (mL/hr) = Total Volume (mL) ÷ Time (hours)

Step 2: Plug in the values
Rate = 1600 mL ÷ 24 hr

Step 3: Calculate
Rate = 66.6667 mL/hr

Step 4: Round to the nearest tenth
Rate ≈ 66.7 mL/hr

A. Radiation Oncology B. Hospice C. Psychiatry D. Surgical oncology

Correct Answer is D

Explanation

A. Radiation oncology is focused on the use of radiation therapy to treat cancer. Since the patient has decided not to continue with treatment, this specialty would not be the most appropriate recommendation in this situation.
B. Hospice care is designed to provide comfort and support for individuals with terminal illnesses who are no longer seeking curative treatments. It focuses on improving the quality of life, pain management, and providing emotional and spiritual support for the patient and their family. This is the most appropriate referral in the context of a terminal cancer diagnosis where the patient has chosen to discontinue curative treatment.
C. Psychiatry may be helpful if the patient is experiencing significant emotional or psychological distress, but it is not the primary specialty needed for a terminal cancer patient who is opting for comfort-focused care.
D. Surgical oncology would be involved if surgery were part of the cancer treatment plan. Since the patient has chosen not to continue treatment, surgery is unlikely to be appropriate at this time.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer 1600 mL of total parental nutrition (IPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr? (Do not use trailing zeros, use a leading zero if it applies)

Correct Answer is ["66.7"]

Explanation

A patient has been diagnosed with terminal cancer and has decided to not continue with treatment. The nurse would recommend a consult with which healthcare specialty?

Correct Answer is D

Explanation

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?

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