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A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak and tell his, he has very very heavy. Curently, the clients neurologic examination is normal. About what drug should the nurse plan to teach the client?
- A. Altephase (Activase)
- B. Clopolgel (Plliniv)
- C. Heparin sodium
- D. Manitol (Omitrol)
Correct Answer: B
Rationale: This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed against to clpolgelgel on discharge. Altephase is used for ischemic stroke. Heparin and mannitol are not used for this condition.
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A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)
- A. Discharging the client on a statin medication
- B. Providing the client with comprehensive therapies
- C. Meeting goals for nutrition within 1 week
- D. Providing and charting stroke education
- E. Preventing venous thrombembolism
Correct Answer: A,D,E
Rationale: Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thrombembolism. The client must be assigned for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures.
A client had is em/bolectomy for an arteri/ovenous malformation (AVM). The client is now reporting a severe headache and has vom/ited. What action by the nurse takes priority?
- A. The client is being informed consent.
- B. Assess the clients vital signs.
- C. Notify the Rapid Response Team.
- D. Raise the head of the bed.
Correct Answer: C
Rationale: The client may to experiencing a re/hed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team but getting immediate medical attention is the priority. Admin/tering pain medication may not be warranted if the client are the return to emergency. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)
- A. Client with an initial neurological (all health)
- B. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38
- C. Client with a mild forgetfulness and a slight limp
- D. Client who has a past hospitalization for all suicide attempt
- E. Client who is unable to wait or eat 1 weeks post-stroke.
Correct Answer: A,B,D,E
Rationale: Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH) Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and slight limp is not with a few priority for this referral.
A client has a brain abscess and is receiving phenyton [Dilantin]. The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
- A. Brain abscesses can lead to seizures as a complication.
- B. Documenting febrile seizures with an abscess.
- C. Seizures always occur in clients with brain abscesses.
- D. This drug is need to sedate the client with an abscess.
Correct Answer: A
Rationale: Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenystion is need to a prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.
A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-PA, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) mL/hr
- A. 1.2 mL/hr
- B. 1.4 mL/hr
- C. 1.6 mL/hr
- D. 1.8 mL/hr
Correct Answer: B
Rationale: The client weighs 225 pounds, which is approximately 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the client's dose is 90 mg. 10% of the dose (9 mg) is given as a bolus IV over the first minute, leaving 81 mg to be infused over 60 minutes. Therefore, 81 mg ÷ 60 min = 1.35 mg/min, which rounds to 1.4 mL/hr.