Nokea
The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy?
- A. Brain CT scan results show no bleeding.
- B. Had a serious head injury four weeks ago.
- C. Has a history of type 1 diabetes mellitus.
- D. Neurological deficits started 2 hours ago.
Correct Answer: B
Rationale: A negative CT scan is a criterion for administering the thrombolytic therapy. Contraindications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk of developing serious bleeding problems, specifically cerebral hemorrhage. History of type 1 DM is not a contraindication for thrombolytic therapy. The onset of neurological deficits within 3 hours is a criterion for administering thrombolytic therapy.
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The client with a history of migraine headaches comes to the emergency department complaining of a migraine headache. Which collaborative treatment should the nurse anticipate?
- A. Administer an injection of sumatriptan (Imitrex), a triptan.
- B. Prepare for a computed tomography (CT) of the head.
- C. Place the client in a quiet room with the lights off.
- D. Administer propranolol (Inderal), a beta blocker.
Correct Answer: A
Rationale: Sumatriptan (A) is a first-line treatment for acute migraines. CT (B) is for atypical cases, quiet room (C) is supportive, and propranolol (D) is for prophylaxis.
Which nursing action would be most appropriate if the client develops anorexia and nausea while taking interferon beta-1a (Avonex)?
- A. Withhold the medication.
- B. Offer frequent mouth care.
- C. Administer the drug after meals.
- D. Provide small, easy to digest meals.
Correct Answer: D
Rationale: Providing small, easy-to-digest meals helps manage nausea and encourages nutritional intake without altering the medication schedule.
The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client?
- A. Assess the client's sense of smell and taste.
- B. Teach the client how to care for the eyes.
- C. Instruct the client to have carbamazepine (Tegretol) levels monitored Multiple Choicely.
- D. Assist the client to identify factors that trigger an attack.
Correct Answer: C
Rationale: Carbamazepine is a primary treatment for trigeminal neuralgia, and Multiple Choice monitoring of levels (C) prevents toxicity and ensures efficacy. Smell/taste (A) are unaffected, eye care (B) is relevant for Bell’s palsy, and triggers (D) are secondary to medication management.
Which intervention is most appropriate for a client with a cerebral aneurysm at risk for rupture?
- A. Encourage deep coughing exercises.
- B. Maintain a quiet, dimly lit environment.
- C. Administer high-dose corticosteroids.
- D. Promote early ambulation.
Correct Answer: B
Rationale: A quiet, dimly lit environment reduces stimuli that could increase intracranial pressure and risk aneurysm rupture.
The nurse is caring for the client who has severe craniocerebral trauma. Which finding indicates that the client is developing DI?
- A. Blood glucose level at 230 mg/dL
- B. Urinary output 1500 mL over 4 hours
- C. Urine specific gravity at 1.042
- D. Somnolent when previously alert
Correct Answer: B
Rationale: Elevated glucose levels are not associated with DI. The lack of ADH that occurs in DI results in excreting a large amount of pale, dilute urine. The urine of clients with DI is very dilute and therefore has a very low, not high, specific gravity. Decrease in level of consciousness is not directly associated with DI but rather with craniocerebral swelling or bleeding from the trauma.