Nokea
The nurse is caring for a client who sustained an ischemic cerebrovascular accident (CVA) three hours ago. The client's most recent blood pressure was 168/101 mm Hg. The nurse should take which action?
- A. Position the head of the bed completely flat
- B. Continue to monitor the client
- C. Obtain orthostatic blood pressure
- D. Request a prescription for an antihypertensive
Correct Answer: B
Rationale: Blood pressure monitoring is appropriate as 168/101 mmHg is within acceptable limits for acute ischemic stroke unless thrombolytics are planned.
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A 24-year old woman presents to the emergency department and appears as shown in the exhibit. What type of injury does this assessment finding suggest?
- A. CSF leak
- B. Basilar skull fracture
- C. Brown-Sequard syndrome
- D. Subarachnoid hemorrhage
Correct Answer: B
Rationale: Without the exhibit, basilar skull fracture is assumed due to context (e.g., raccoon eyes or CSF leak signs).
This nurse is caring for a client who is receiving prescribed carbamazepine. Which of the following findings would indicate a therapeutic response?
- A. Decreased mood lability
- B. Steady gait
- C. Urinary continence
- D. Increased bone mass
Correct Answer: B
Rationale: Carbamazepine is an anticonvulsant used for seizures, and a steady gait indicates reduced seizure activity or improved neurological stability. Mood lability, urinary continence, and bone mass are not primary therapeutic outcomes.
The nurse is caring for a client with an acute migraine headache. Which medication would the nurse anticipate a prescription for an acute migraine? Select all that apply.
- A. Ketorolac
- B. Nitroglycerin
- C. Topiramate
- D. Dexamethasone
- E. Hydromorphone
- F. Acetaminophen-caffeine
Correct Answer: A,F
Rationale: Ketorolac (an NSAID) and acetaminophen-caffeine are used for acute migraine relief. Nitroglycerin can worsen migraines, topiramate is for prevention, dexamethasone is not standard, and hydromorphone is not typically used for migraines.
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.
The following scenario applies to the next 1 items
The nurse is caring for a 71-year-old female in the emergency department (ED)
Item 1 of 1
Nurses' Note Diagnostics
1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation.
1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan.
1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results.
1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute
The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated
For each potential nursing intervention, click to specify if the intervention is indicated or not Indicated:
- A. Obtain an accurate weight
- B. Insert two peripheral vascular access devices
- C. Insert a nasogastric tube (NGT) immediately after alteplase infusion
- D. Obtain baseline laboratory work (CBC, CMP, aPTT, PT/INR) prior to infusion of alteplase
- E. Plan for admission to the medical-surgical floor
- F. Perform frequent neurological assessments
- G. Notify the physician if the systolic blood pressure is 185 mm Hg or greater
Correct Answer: A,A,B,A,B,A
Rationale: Accurate weight is critical for calculating the correct dose of alteplase for stroke treatment. Two peripheral IVs are needed for alteplase administration to ensure reliable access for the thrombolytic and other medications. NGT insertion is not immediately indicated post-alteplase unless swallowing difficulties are confirmed, to avoid complications. Baseline labs are essential to assess bleeding risk before administering thrombolytics like alteplase. Stroke patients receiving alteplase typically require ICU admission for close monitoring, not a medical-surgical floor. Frequent neurological assessments are critical post-alteplase to monitor for neurological changes or complications.