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 nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse?
- A. The vital signs are documented as T 100.2°F, P 80, R 18, and BP 136/78.
- B. The client complains of generalized body aches and pains.
- C. Positive results are reported from the enzyme-linked immunosorbent assay (ELISA).
- D. The client becomes lethargic and is difficult to arouse using verbal stimuli.
Correct Answer: D
Rationale: Lethargy and difficulty arousing (D) indicate neurological deterioration, requiring immediate intervention. Mild fever (A), body aches (B), and positive ELISA (C) are expected.
The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?
- A. Keep oxygen via nasal cannula on at all times.
- B. Administer low-dose subcutaneous anticoagulants.
- C. Perform active lower extremity ROM exercises.
- D. Refer to a speech therapist for ventilator-assisted speech.
Correct Answer: B
Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (B) prevent thromboembolism. Oxygen (A) is unnecessary without respiratory issues, active ROM (C) is not feasible due to paralysis, and speech therapy (D) is irrelevant.
The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply.
- A. Assess for deep vein thrombosis.
- B. Administer intravenous anticoagulant.
- C. Monitor intake and output strictly.
- D. Apply warm compresses to the eyes.
- E. Perform passive range-of-motion exercises.
Correct Answer: A,C,E
Rationale: Assessing DVT (A), monitoring intake/output (C), and passive ROM (E) prevent complications. Anticoagulants (B) increase bleeding risk, and warm compresses (D) are not indicated.
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.
Which of the following indicates an autonomic nervous system manifestation of a seizure?
- A. Numbness and tingling of the hands
- B. Changes in taste and speech
- C. Flushing and increased sweating
- D. A subjective aura or sensation
Correct Answer: C
Rationale: Flushing and increased sweating are autonomic nervous system manifestations that can occur during a seizure, reflecting involuntary physiological changes.