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 ["400"]
Explanation
Step 1: Convert the volume of fluid to be infused from mL to L (since the rate is usually measured in mL/hr):
200 mL = 200 mL (No conversion needed as the volume is already in mL)
Step 2: Convert the time for infusion from minutes to hours (since the rate is usually measured in mL/hr):
30 minutes = 30 ÷ 60 = 0.5 hours
Step 3: Calculate the rate (volume ÷ time):
Rate = Volume ÷ Time
Rate = 200 mL ÷ 0.5 hours
Rate = 400 mL/hr
The nurse should program the infusion pump to deliver at a rate of 400 mL/hr.
Correct Answer is D
Explanation
Choice A reason: Heat and cold therapy can help manage symptoms but are not directly related to health promotion and teaching.
Choice B reason: Avoiding foods containing purine is more related to conditions like gout, not rheumatoid arthritis.
Choice C reason: Immobilization of affected joints is not a health promotion strategy and can actually worsen rheumatoid arthritis symptoms over time.
Choice D reason: Prevention through nutrition and exercise is a key component of health promotion and teaching for clients with rheumatoid arthritis, as it can help manage symptoms and improve overall health.
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