Twenty minutes after the onset of symptoms, an adult client presents to the emergency department with slurred speech and right-sided weakness. After a computerized tomography (CT) scan reveals a non-hemorrhagic stroke, the nurse administers alteplase. Which assessment finding warrants immediate intervention?
Headache with blurred vision.
Lower extremity edema.
Paroxysmal supraventricular tachycardia.
Frequent premature ventricular contractions.
The Correct Answer is A
Choice A reason: A headache with blurred vision following alteplase administration could indicate intracranial hemorrhage, which requires immediate intervention.
Choice B reason: Lower extremity edema is not typically an immediate concern post-alteplase administration unless it indicates a deep vein thrombosis.
Choice C reason: Paroxysmal supraventricular tachycardia requires monitoring, but it is not as urgent as a headache with blurred vision, which could signify a life-threatening complication.
Choice D reason: Frequent premature ventricular contractions should be monitored, but they are not as critical as a headache with blurred vision post-alteplase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: Shaking that affects a child's handwriting could indicate a neurological issue or other medical conditions that require immediate attention. It's essential for teachers to report such observations to the school nurse for proper assessment and intervention.
Choice B reason: Excessive thirst and frequent urination can be signs of diabetes, especially in children. Early detection and management are crucial for the child's health, making it important for teachers to report these symptoms.
Choice C reason: While refusal to complete homework could be related to behavioral or social issues, it is not typically a medical concern that requires the school nurse's intervention unless accompanied by other signs of distress or health problems.
Choice D reason: Bruises could be common in children due to their active nature, especially after a weekend. However, unless there is a pattern or other concerning signs of abuse or a medical condition, bruises alone may not necessitate a referral to the school nurse.
Choice E reason: Sunburn with blisters is a sign of a second-degree burn, which can be serious, especially in children. It is important for teachers to report this to the school nurse so that the child can receive proper care and parents can be advised on treatment and prevention.
Correct Answer is C
Explanation
Choice A reason: Applying a water-soluble lubricant to the catheter is not recommended during tracheostomy suctioning as it may introduce contaminants.
Choice B reason: Instilling sodium chloride before suctioning is not a standard practice and can lead to complications such as edema.
Choice C reason: Wearing protective goggles is important to protect the nurse from potential splashes of bodily fluids during the suctioning process.
Choice D reason: Instructing the client to cough as the suction tip is removed is not recommended as it can cause discomfort and potential harm to the tracheal lining.
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