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As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.
- A. INR above 1.0
- B. Recent intracranial pathology
- C. Sudden symptom onset
- D. Current anticoagulation therapy
- E. Symptom onset greater than 3 hours prior to admission
Correct Answer: B,D,E
Rationale: Recent intracranial pathology, anticoagulation (INR >1.7), and symptom onset >3 hours are thrombolytic contraindications. INR above 1.0 is too low, and sudden onset is not a contraindication.)
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A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?
- A. Acute pain
- B. Septicemia
- C. Bleeding
- D. Seizures
Correct Answer: C
Rationale: Bleeding is the primary complication of t-PA due to its thrombolytic action. Pain, septicemia, and seizures are less likely.
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?
- A. Evidence of hemorrhagic stroke
- B. Blood pressure of 180/110 mm Hg
- C. Evidence of stroke evolution
- D. Previous thrombolytic therapy within the past 12 months
Correct Answer: A
Rationale: Thrombolytic therapy is contraindicated in hemorrhagic stroke due to bleeding risk. High BP, stroke evolution, or prior thrombolytic use are not absolute contraindications.
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized?
- A. Prevent complications of immobility.
- B. Maintain and improve cerebral tissue perfusion.
- C. Relieve anxiety and pain.
- D. Relieve sensory deprivation.
Correct Answer: B
Rationale: Cerebral perfusion is a priority physiologic need for survival in hemorrhagic stroke. Other goals are important but secondary.
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities?
- A. Place the patient in the prone position for 30 minutes/day.
- B. Assist the patient in acutely flexing the thigh to promote movement.
- C. Place a pillow in the axilla when there is limited external rotation.
- D. Place patients hand in pronation.
Correct Answer: C
Rationale: A pillow in the axilla prevents shoulder adduction, reducing deformity risk. Prone positioning aids hip extension, not daily for 30 minutes. Acute thigh flexion may cause edema, and hand pronation is less functional than supination.
When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal?
- A. Head turned slightly to the right side
- B. Elevation of the head of the bed
- C. Position changes every 15 minutes while awake
- D. Extension of the neck
Correct Answer: B
Rationale: HOB elevation promotes venous drainage, reducing ICP. Neck extension or frequent position changes may increase ICP, and head turning is less effective.