What is the main side effect of IV Thrombolytic therapy TPA?

Choice A: Careful, frequent monitoring of respiratory function, including blood gases is correct, as it can detect and prevent hypoxia, hypercapnia, and acid-base imbalance that can affect the brain and other organs.

Choice B: Monitor for signs and symptoms of complications is correct, as it can identify and treat potential problems such as hemorrhage, infection, seizures, or increased intracranial pressure.

Choice C: Monitor fluid status and laboratory data is correct, as it can maintain fluid and electrolyte balance and prevent dehydration, overhydration, or cerebral edema.

Choice D: All of the above is correct, as all of these assessments are important for the patient undergoing intracranial surgery.

Choice A: When patient is fully oriented is incorrect because it is a positive sign of recovery from a concussion. It means that the patient is aware of their person, place, time, and situation. The nurse should monitor the patient's orientation status but does not need to report it to the doctor immediately.

Choice B: Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety are correct because they are signs of worsening brain injury or complications from a concussion. They may indicate increased intracranial pressure, bleeding, swelling, or infection in the brain. The nurse should report these symptoms to the doctor immediately and prepare for further diagnostic tests or interventions.

Choice C: When patient is easy to arouse is incorrect because it is also a positive sign of recovery from a concussion. It means that the patient responds quickly and appropriately to verbal or physical stimuli. The nurse should monitor the patient's level of consciousness but does not need to report it to the doctor immediately.

Choice D: All of the above are incorrect because only choice b) requires immediate reporting to the doctor. Choices a) and c) are normal or expected outcomes of a concussion and do not indicate any danger or complication. The nurse should use clinical judgment and follow the guidelines for concussion management and care.