Intracranial Reg

A nurse is caring for a client with stroke symptoms. In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered?

• 6 hours after the onset of stroke symptoms

• 3 hours after the onset of stroke symptoms

• 12 hours after onset of stroke symptoms

• 3 hours after arrival to to the emergency department

Order: Erythromycin 750 mg
Available: Erythromycin 250 mg capsules

How many capsules are you giving to the client?

ANSWER IN Numbers ONLY

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

• Bowel sounds

• Pupil size and pupillary response

• Cholesterol level

• Echocardiogram

A nurse is caring for two clients that have been admitted to the unit with a hemorrhagic stroke. The nurse assistant gives the the following vitals for the two clients. Which of the following abnormal vital signs is the most concerning?

• 130 heart rate

• 55 heart rate

• 90/53 mmHg BP

• 210/112 mmHg BP

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

• Vomiting continues.

• Intracranial pressure (ICP) is increased.

• The client needs mechanical ventilation

• Blood is anticipated in the cerebrospinal fluid (CSF).

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?

• The patient has dysphasia.

• The patient has atrial fibrillation.

• The patient reports that symptoms began with a severe headache.

• The patient has a history of brief episodes of right-sided hemiplegia.

 Which action by the nurse is best after assisting the practitioner with a lumbar puncture (LP) for a school-age client who presents with symptoms indicative of meningitis?

• Apply EMLA cream to the site for pain management.

• Encourage the child to drink fluids, if not contraindicated.

• Maintain the child in a flat position for 2 hours after the lumbar puncture

• Assess for clinical manifestations of an allergic reaction to contrast.

 The nurse working at the emergency department in a children's hospital receives a 10 year old school going client with nuchal rigidity, fever and a positive Kernig's sign. What should be the nurses next action?

• Give a tepid sponge bath.

• Refer the case to infection control.

• the child is put in droplet isolation

• Arrange for a lumbar puncture.

 What is the priority action by the nurse in the provision of care for a client admitted with a suspected diagnosis of acute meningitis?

• Ensure the room is dimly light

• Ensure the correct precautions are on the room

• Place two 18 gauge IV catheters

• Have the patient sign consents for a lumbar puncture

 The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

• Lateral recumbent, with a pillow under the hip

• Prone, in a slight Trendelenburg’s position

• Lateral recumbent, with legs pulled up and head bent down onto the chest

• Prone, with a pillow under the abdomen.