Within how many hours does tissue plasminogen activator (TPA) need to be given to be most successful for a client with an ischemic stroke?

Correct Answer: B

Rationale: In the management of ischemic stroke, the administration of tissue plasminogen activator (TPA) is crucial in improving outcomes. The correct answer is B) 3 hours. This is because TPA is most effective when given within the first 3 hours of symptom onset. Administering TPA within this time frame can help dissolve the blood clot causing the ischemic stroke and restore blood flow to the affected area of the brain, minimizing long-term damage. Option A) 6 hours is incorrect because waiting this long reduces the efficacy of TPA and increases the risk of complications. Option C) 8 hours and Option D) 10 hours are even further beyond the optimal window for TPA administration, significantly decreasing its effectiveness. Educationally, understanding the time-sensitive nature of TPA administration emphasizes the importance of rapid assessment, diagnosis, and treatment in stroke care. This knowledge underscores the critical role of healthcare providers in recognizing and responding promptly to stroke symptoms to maximize the chances of a positive outcome for the patient.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Fractures. When a client with a neurological deficit is immobile and is moved to another bed, they may experience pain in their leg due to the potential development of fractures. Prolonged immobility can lead to bone demineralization and weakness, making the bones more susceptible to fractures, especially during movements or transfers. Option A) TIA's (Transient Ischemic Attacks) are not directly related to the scenario described. TIAs are brief episodes of neurological dysfunction caused by a temporary disruption of blood flow to the brain, often manifesting as stroke-like symptoms. Option B) Paralysis refers to the loss of muscle function in part of your body. While paralysis can be a complication of some neurological conditions, it is not the most likely immediate complication in this case scenario. Option D) Bruising is not the most likely complication in this case. While bruising can occur due to physical trauma, such as bumping into objects during movement, the potential for fractures is higher in this context due to the combination of immobility and relocation of the client. Educationally, understanding the risks associated with immobility in clients with neurological deficits is crucial for healthcare providers. Proper techniques for transferring immobile clients and the importance of preventive measures, such as repositioning and monitoring for signs of discomfort or injury, are essential components of care to prevent complications like fractures.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Cerebral circulation may be maintained through the circle of Willis. The circle of Willis is a circulatory anastomosis that provides collateral circulation to the brain by connecting the anterior and posterior circulations. When there is a blockage in a major cerebral artery like the middle cerebral artery due to atherosclerotic plaque, blood flow can be diverted through the circle of Willis, helping to maintain cerebral perfusion to some extent. Option A is incorrect because distended jugular veins are not a typical finding in a patient with atherosclerotic plaque in the middle cerebral artery. Option C is incorrect because the loss of temporal and parietal lobe function would be more related to a specific region affected by a stroke rather than a general blockage in the middle cerebral artery. Option D is incorrect because increased pressure in the middle cerebral artery would not back up into the vertebral arteries due to the separate vascular territories they supply. Understanding the anatomy and physiology of the cerebral circulation is crucial in nursing practice to assess and manage patients with neurological issues such as strokes. Recognizing the role of collateral circulation through structures like the circle of Willis can help nurses anticipate potential complications and tailor interventions to optimize cerebral perfusion in patients with vascular occlusions.

Correct Answer: B

Rationale: The correct answer is B) Protects against harmful blood-borne agents. The blood-brain barrier is a crucial physiological mechanism that protects the central nervous system (CNS) from potentially harmful substances circulating in the blood, such as toxins, pathogens, and large molecules. This selective barrier is formed by specialized endothelial cells in the capillaries of the brain, which tightly regulate the passage of substances into the brain tissue. Option A) Protects the brain from external trauma is incorrect because the blood-brain barrier primarily functions to protect the brain from internal threats, not external physical trauma. Option C) Provides for flexibility while protecting the spinal cord is incorrect because the blood-brain barrier specifically refers to the protective mechanism for the brain, not the spinal cord. The spinal cord has its own protective mechanisms. Option D) Forms the outer layer of protective membranes around the brain and spinal cord is incorrect because the blood-brain barrier is not a physical membrane but rather a physiological barrier formed by specialized cells in the brain capillaries. Understanding the role of the blood-brain barrier is essential for healthcare providers as it impacts the treatment of neurological conditions and the delivery of medications to the brain. Educating patients about the blood-brain barrier helps them comprehend the importance of protecting the brain from harmful substances circulating in the bloodstream and the limitations it poses on certain treatments for CNS disorders.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: Paraplegia with a flaccid paralysis. The presence of spinal shock after a spinal cord injury at the C7 level is characterized by a temporary loss of reflexes and muscle tone below the level of injury. This results in flaccid paralysis, where the affected limbs are limp and lack muscle tone. Option B, tetraplegia with total sensory loss, is incorrect because spinal shock typically presents with flaccid paralysis rather than spastic paralysis and is more localized to the area of injury rather than affecting all limbs. Option C, total hemiplegia with sensory and motor loss, is incorrect as hemiplegia refers to paralysis affecting one side of the body, not both sides as seen in this case. Option D, spastic tetraplegia with loss of pressure sensation, is incorrect because spinal shock is characterized by flaccid paralysis, not spastic paralysis. Educationally, understanding the manifestations of spinal shock is crucial for healthcare providers caring for patients with spinal cord injuries. Recognizing the signs of spinal shock helps in providing appropriate interventions and predicting potential outcomes for the patient's recovery and rehabilitation process.