Nokea
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
- A. Diabetes mellitus
- B. Meniere's disease
- C. Excessive cerumen
- D. Exposure to loud noise
- E. Excessive fluid
Correct Answer: A,B,D
Rationale: Diabetes, Meniere's disease, and loud noise exposure cause sensorineural hearing loss by damaging the inner ear or auditory nerve.
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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.
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.
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.
The nurse is caring for a client who has been prescribed carbidopa-levodopa for Parkinson's disease. The nurse should instruct the client that this medication may cause Select all that apply.
- A. Urine to appear darker
- B. Hallucinations
- C. Dizziness upon standing
- D. Dry, non-productive cough
- E. Painful rash that spreads and blisters
Correct Answer: A,B,C
Rationale: Carbidopa-levodopa can cause darker urine (due to metabolism), hallucinations (a CNS side effect), and dizziness upon standing (orthostatic hypotension). Dry cough and rashes are not typical side effects.
The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following?
- A. Apraxia
- B. Agraphia
- C. Agnosia
- D. Aphasia
Correct Answer: C
Rationale: Agnosia is the inability to recognize familiar objects or people, common in dementia.