You are providing care for a patient with an acute hemorrhagic stroke. The patient's husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response?

Correct Answer: C

Rationale: The correct answer is C) Alteplase dissolves clots and may cause more bleeding into your wife's brain. In the context of an acute hemorrhagic stroke, where bleeding in the brain has already occurred, administering a clot-busting medication like alteplase can exacerbate the bleeding, leading to further damage and complications. It is crucial to differentiate between ischemic strokes (where a clot blocks blood flow) and hemorrhagic strokes (where a blood vessel ruptures), as the management approaches are different. Option A is incorrect because it does not address the specific risk of using alteplase in a hemorrhagic stroke. Option B is incorrect as alteplase is not primarily used for acute heart attacks but for ischemic strokes. Option D is incorrect as a history of gallbladder surgery is not a contraindication for alteplase use in stroke management. Educationally, understanding the rationale behind the use or avoidance of specific treatments in different types of strokes is vital for nursing practice, especially in emergency situations like acute strokes. It highlights the importance of accurate assessment, diagnosis, and treatment selection based on the underlying pathology to optimize patient outcomes and prevent harm.

Correct Answer: A

Rationale: The correct answer is A) Atropine sulfate. In the context of an edrophonium (Tensilon) test, which is used to diagnose myasthenia gravis, atropine sulfate must be available as an antidote. Edrophonium is a cholinesterase inhibitor that temporarily increases acetylcholine levels at the neuromuscular junction, potentially causing cholinergic crisis characterized by excessive muscarinic stimulation. Atropine sulfate, an anticholinergic agent, is used to counteract the muscarinic effects by blocking the action of acetylcholine at muscarinic receptors, effectively reversing the cholinergic crisis symptoms. The other options are incorrect because: - B) Diazepam (Valium) is a benzodiazepine used for its anxiolytic and anticonvulsant properties, not for reversing cholinergic crisis. - C) Ephedrine is a sympathomimetic amine that acts on adrenergic receptors, not muscarinic receptors like atropine sulfate. - D) Corticosteroids are anti-inflammatory agents that are not indicated for acute cholinergic crisis management. Understanding the appropriate antidotes and interventions for potential complications during diagnostic tests is crucial for nursing practice. Knowing the specific antidote needed for cholinergic crisis in the context of an edrophonium test is essential to ensure prompt and effective management of adverse reactions, thereby improving patient safety and outcomes.

Correct Answer: B

Rationale: The correct answer is B) Muscle spasms are beginning to occur. Joe's leg movement of pulling away during the bath indicates the onset of muscle spasms, which is a common neurological response post-injury. This can be attributed to the hyperexcitability of nerves in the injured area, leading to involuntary muscle contractions. It is crucial for the nurse to recognize this sign as it may indicate the need for interventions to manage the muscle spasms and prevent further complications such as contractures. Option A) He is embarrassed about having to be bathed is incorrect because the behavior described is more indicative of a physiological response rather than an emotional one. Option C) Paralysis is diminishing due to reduction in edema is incorrect because a reduction in paralysis due to decreased edema would not manifest as muscle spasms but rather as improved voluntary muscle movement. Option D) He is adjusting negatively to his disability is incorrect because the behavior described is not a result of psychological adjustment but rather a physiological response related to the neurological injury. In an educational context, understanding the significance of changes in muscle tone and movement post-neurological injury is essential for nurses caring for patients with such conditions. Recognizing early signs of muscle spasms can help in implementing appropriate interventions to prevent complications and promote optimal recovery.

Correct Answer: A

Rationale: Proper body alignment is crucial for hemiplegic patients to prevent complications like contractures. In this case, using a footboard helps maintain neutral ankle position, preventing plantar extension. Trochanter rolls aid in hip alignment, reducing internal hip rotation. Pillows support the affected side, preventing shoulder abduction. Choosing option A, plantar extension, as the correct answer is supported by the need to maintain proper foot alignment to prevent deformities. Plantar extension can lead to issues like foot drop and contractures, hence aligning the foot is essential. Option B, shoulder abduction, is incorrect as the question focuses on lower body alignment, not upper body positioning. Similarly, internal and external hip rotation (options C and D) are controlled by trochanter rolls, not footboard use. Educationally, understanding proper body alignment strategies for hemiplegic patients is vital for nursing practice. It promotes patient comfort, prevents complications, and supports overall rehabilitation efforts. Nurses must be knowledgeable about these interventions to provide holistic care and promote optimal patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) straight in bed alternating head position from flat to 30° elevation and left leg abducted. This position helps prevent dislocation of the prosthetic head and hip contracture by maintaining proper alignment of the body. Placing the head at a slight elevation reduces pressure on the hip joint. Abducting the left leg also helps prevent hip contracture by keeping the joint in a neutral position. Option B) diagonally toward the right side of the bed with legs together would not provide optimal alignment for preventing hip dislocation and contracture. Option C) flat on back in bed for first 48 hours with legs adducted may increase the risk of hip contracture due to prolonged adduction. Option D) on the right side only with the left leg in front of the right leg does not promote equal weight distribution and proper alignment. In an educational context, understanding proper body alignment in bed is crucial for preventing complications such as hip dislocation and contractures, especially in patients with prosthetic hips. Nurses must be knowledgeable about positioning techniques to promote patient comfort, prevent complications, and facilitate optimal recovery.