The nurse receives a patient from the emergency department following administration of a fibrinolytic medication, TPA, for a large anterior wall myocardial infarction. The priority assessment for this patient would be which of the following?
Urine output
Vital signs
Name of the patient's dog
Neurological status
The Correct Answer is D
Choice A reason: Urine output is important but not the priority after administration of fibrinolytic medication.
Choice B reason: Vital signs are routinely monitored but the priority is assessing for any signs of complications from the medication, such as bleeding or stroke.
Choice C reason: The name of the patient's dog is irrelevant to the patient's medical care and assessment.
Choice D reason: Neurological status is the priority to monitor for signs of intracranial hemorrhage, a potential complication of fibrinolytic therapy.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: An embolic stroke is caused by an embolus traveling to the brain and blocking a blood vessel. The symptoms described do not specifically indicate an embolic stroke.
Choice B reason: A hemorrhagic stroke, which is bleeding within the brain, often presents with a sudden, severe headache, vomiting, and a change in consciousness, aligning with the symptoms described.
Choice C reason: A thrombotic stroke is caused by a thrombus forming in a blood vessel in the brain. While it can cause similar symptoms, the sudden severe headache is more characteristic of a hemorrhagic stroke.
Choice D reason: A transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain. The symptoms usually resolve within minutes to hours and do not typically include a severe headache or vomiting.
Correct Answer is C
Explanation
Choice A reason: Stopping seizure medication such as phenytoin without medical advice can lead to life-threatening seizures. It is not recommended to stop after a set period of being seizure-free without consulting a healthcare provider.
Choice B reason: Phenytoin should not be taken only during periods of stress; it is intended to be used consistently to maintain therapeutic levels in the body.
Choice C reason: Phenytoin may need to be continued indefinitely, depending on the individual's condition and the doctor's recommendation. It is often used as a long-term treatment for seizure control.
Choice D reason: This statement is misleading; while phenytoin helps control seizures, it does not cure the underlying condition causing them.
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