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 C
Explanation
Choice A reason: Discussing side effects with a healthcare provider is important, but it does not address the immediate concern of safely discontinuing the medication. The provider can adjust the treatment plan if side effects are intolerable.
Choice B reason: Reminding the client of the therapeutic effects is helpful for understanding the benefits of the medication, but it does not provide guidance on how to safely discontinue it.
Choice C reason: Gradual tapering is the recommended approach to discontinuing antidepressants to minimize the risk of withdrawal symptoms and ensure the stability of the client's mental health.
Choice D reason: While side effects may dissipate over time, this does not provide a solution for the client who wishes to stop the medication now. It is also not guaranteed that all side effects will diminish.
Correct Answer is A
Explanation
Choice A reason: Asking the client to describe the pain is essential as it provides subjective information about the pain's quality, intensity, and impact on daily activities, which is crucial for assessing osteoarthritis pain.
Choice B reason: Observing body language and movement can offer insights into the pain's impact on function, but it does not replace the client's verbal description of the pain experience.
Choice C reason: Identifying effective pain relief measures is part of managing osteoarthritis but does not directly assess the quality of the client's knee pain.
Choice D reason: Providing a numeric pain scale is a method to quantify pain intensity but may not fully capture the quality or characteristics of the pain.
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