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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Level of consciousness is the most basic and sensitive indicator of altered brain function and is considered the most reliable indicator of neurologic status.

Choice B reason: Temperature is not a direct indicator of neurologic status and does not change as rapidly in response to neurologic events.

Choice C reason: Blood pressure can be aﬀected by neurologic changes, but it is not as sensitive or specific as the level of consciousness.

Choice D reason: Pulse rate is not a direct indicator of neurologic status and can be inﬂuenced by a variety of non- neurologic factors.

A. Ask about numbness or tingling of the hands and arms. B. Suggest the patient alternate use of heat and cold to the neck. C. Provide information about therapeutic neck exercises. D. Teach about the use of nonsteroidal anti-inﬂammatory drugs (NSAIDs).

Correct Answer is A

Explanation

Choice A reason: Asking about numbness or tingling is important to rule out neurological issues that could be causing the neck pain.

Choice B reason: While heat and cold therapy may provide relief, it is not the first action to take before assessing the cause of the pain.

Choice C reason: Providing information about exercises is helpful but should come after an initial assessment.

Choice D reason: Teaching about NSAIDs is part of pain management but should follow an assessment of symptoms and potential causes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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