Nokea
The nurse is caring for a client receiving intravenous (IV) alteplase for a cerebrovascular accident (CVA). The nurse understands that this medication has reached its therapeutic effect when the client is assessed to have
- A. Increase in the Glasgow Coma Scale
- B. Unintelligible speech
- C. Bleeding at their gum line
- D. Increase in pulse and decrease in blood pressure
Correct Answer: A
Rationale: Alteplase is a thrombolytic used to dissolve clots in acute ischemic stroke, improving neurological function, as indicated by an increased Glasgow Coma Scale. Unintelligible speech, bleeding, and vital sign changes are not therapeutic effects.
You may also like to solve these questions
The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding?
- A. Diplopia
- B. Butterfly rash
- C. Facial muscle weakness
- D. Shuffling gait
- E. Ptosis
Correct Answer: A,C,E
Rationale: Diplopia, facial muscle weakness, and ptosis are common in myasthenia gravis due to neuromuscular junction dysfunction.
A nurse is caring for a client with a history of seizures who is at risk for injury. Which intervention is the highest priority to reduce the client's risk of injury?
- A. Keeping the client's room dimly lit to minimize visual stimulation
- B. Administer antiepileptic medications as prescribed.
- C. Implement seizure precautions, including padded side rails up and the bed in the lowest position.
- D. Provide education to the client and family about seizure triggers and safety measures.
Correct Answer: C
Rationale: Seizure precautions directly reduce injury risk during a seizure by ensuring a safe environment.
The ICU nurse assesses a comatose patient with a known lesion to the medulla. Which breathing pattern would the nurse expect to assess?
- A. Cheyne-Stokes
- B. Apneustic breathing
- C. Central neurogenic hyperventilation
- D. Cluster breathing
Correct Answer: B
Rationale: Medulla lesions often cause apneustic breathing, characterized by prolonged inspiratory pauses.
The nurse is caring for a client with Huntington's disease. Which of the following assessment findings would be expected?
- A. Halitosis
- B. Chorea
- C. Hallucinations
- D. Hematemesis
- E. Weight loss
Correct Answer: B,E
Rationale: Chorea (involuntary movements) and weight loss are hallmark symptoms of Huntington's disease.
The nurse is caring for a client eight hours postoperative following spinal surgery. Which action is essential for the nurse to take?
- A. Assess the client's pain while they receive patient-controlled analgesia (PCA)
- B. Log roll the client when turning the client from side to side
- C. Assist the client with ambulation to the bathroom
- D. Place pillows under the thighs of each leg when the client is supine
Correct Answer: B
Rationale: Log rolling maintains spinal alignment, preventing injury post-spinal surgery.