Question

Drag and drop the clients who should be considered as potential candidates for tissue plasminogen activator (IPA).

Answer 1

Correct Answers:

Client with a cerebral thrombotic infarction.
Computed tomography (CT) shows cerebral embolic infarction.

Rationale :

Cerebral thrombotic infarction

⏺️tPA (tissue plasminogen activator) is indicated for acute ischemic strokes caused by thrombus formation.

⏺️It works by dissolving clots and restoring perfusion to the affected brain tissue.

⏺️Administration must occur within a 3–4.5 hour window from symptom onset.

⏺️Candidates must be screened for absence of bleeding before administration.

⏺️This client is a classic candidate for thrombolytic therapy.

Cerebral embolic infarction

⏺️An embolic infarction is another form of ischemic stroke caused by a traveling clot.

⏺️tPA is effective in breaking down the embolus, restoring blood flow to the brain.

⏺️CT confirmation rules out hemorrhage, which is a strict contraindication.

⏺️Like thrombotic stroke, therapy must be given within the treatment window.

⏺️This client is also an appropriate candidate for tPA.

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Answer 2

Correct Answers:

Guillain-Barré syndrome (GBS)

Rationale :

♦️Progressive weakness starting in the legs and spreading upward (ascending paralysis) is the classic presentation of Guillain-Barré syndrome, an acute autoimmune polyneuropathy.

♦️The history of a recent respiratory infection aligns with the common post-infectious autoimmune trigger of GBS.

♦️The presence of paresthesia, diminished reflexes, and difficulty walking strongly supports this diagnosis.

♦️Unlike CVA (stroke), which presents with sudden focal deficits, GBS manifests with bilateral and symmetric weakness.

♦️Trigeminal neuralgia causes severe facial pain, and HHS presents with hyperglycemia, dehydration, and altered mental status — neither match this presentation.

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Answer 3

Correct Answers:

Notify the physician.

Rationale :

💎 Sudden chest pain and dyspnea in a client with DVT strongly indicates a pulmonary embolism (PE), a life-threatening emergency.

💎 The priority action is to immediately notify the physician or rapid response team so urgent interventions such as oxygen therapy, anticoagulation, or thrombolytic therapy can be initiated.

💎 Delaying action to perform routine assessments wastes critical time and can worsen hypoxemia and cardiac compromise.

💎 Positioning the client upright and preparing for emergency care follows after notifying the provider.

💎 Prompt reporting ensures rapid treatment and prevents circulatory collapse or death.

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Answer 4

Correct Answers:

Presence of a bruit over the site.

Rationale :

🟣A functioning arteriovenous (AV) fistula must have adequate blood flow to support hemodialysis.

🟣The nurse should auscultate for a bruit and palpate for a thrill, which indicate patency and adequate circulation.

🟣Absence of these findings suggests occlusion or clot formation, requiring immediate evaluation.

🟣Assessing patency is critical before hemodialysis because compromised access will prevent effective therapy.

🟣Documenting these findings ensures safe dialysis initiation and helps preserve vascular access.

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Answer 5

Correct Answers:

Avoid people who are ill
Receive annual flu vaccine
Drink plenty of fluids

Rationale :

Avoid people who are ill

🔷 Older adults have reduced physiologic reserve and a higher risk of influenza complications (e.g., pneumonia, hospitalization), so reducing exposure is critical.

🔷 Limiting close contact with symptomatic individuals lowers viral dose and the likelihood of droplet transmission, especially in crowded indoor settings.

🔷 Combining avoidance with hand hygiene and mask use during peak season further decreases transmission risk.

🔷 People with influenza can be contagious before symptoms and for several days after onset, so exposure minimization remains a prudent prevention strategy.

🔷 This measure is low-cost, immediately actionable, and complements vaccination to provide layered protection.

Receive annual flu vaccine

🔷 The annual vaccine is recommended because influenza viruses undergo antigenic drift, making last year’s immunity incomplete.

🔷 Vaccination reduces the risk of severe disease, hospitalization, and mortality in adults ≥65 years, even if infection occurs.

🔷 Early-season vaccination provides timely protection, but vaccination at any time during flu season still offers benefit.

🔷 Inactivated and recombinant formulations are appropriate in older adults; clinicians may prefer enhanced formulations (e.g., high-dose/adjuvanted) to improve immune response.

🔷 Coupled with non-pharmacologic measures, vaccination forms the cornerstone of influenza prevention for high-risk populations.

Drink plenty of fluids

🔷 Adequate hydration supports mucociliary clearance, helping the respiratory tract trap and remove pathogens.

🔷 Fever and tachypnea increase insensible fluid losses; older adults are prone to dehydration, which can worsen weakness and delirium.

🔷 Maintaining optimal fluid status keeps secretions thin, improving airway comfort and cough effectiveness.

🔷 Routine fluid intake also supports renal perfusion and overall hemodynamic stability, aiding recovery if infection develops.

🔷 Encouraging water and oral rehydration fluids, while limiting excess alcohol/caffeine, is a safe, supportive prevention strategy.

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Answer 6

Correct Answers:

"Shingles results from reactivation of the virus that causes chickenpox"

Rationale :

🔥Shingles occurs due to reactivation of the varicella-zoster virus, the same virus that causes chickenpox.

🔥After initial infection, the virus remains dormant in dorsal root ganglia and can reactivate later in life.

🔥Reactivation risk increases with aging, stress, or immunosuppression, leading to painful vesicular eruptions.

🔥Shingles is not caused by new exposure, but rather latent viral activity.

🔥This explanation helps the client understand that shingles is linked to their childhood chickenpox infection.

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Answer 7

Correct Answers:

Dizziness

Rationale :

❤️Older adults often present with atypical MI symptoms, such as dizziness, fatigue, confusion, or syncope, rather than classic chest pain.

❤️Dizziness occurs due to reduced cardiac output and cerebral perfusion when the myocardium is ischemic.

❤️Recognition of atypical signs is critical to prevent delayed diagnosis and treatment.

❤️This population may lack the usual chest pain due to neuropathy, altered pain perception, or comorbid conditions.

❤️Early identification ensures prompt cardiac monitoring, diagnostic testing, and intervention.

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Answer 8

Correct Answers:

Continue to monitor and record hourly output.

Rationale :

💧A urine output of 60 mL then 70 mL/hr equals >30 mL/hr, which is within the normal expected range for an adult.

💧This indicates that the client’s renal perfusion and fluid balance are adequate.

💧No immediate intervention is required; the nurse should continue monitoring and recording hourly outputs.

💧Accurate monitoring is vital postoperatively to detect early signs of hypovolemia or acute kidney injury.

💧Routine evaluation prevents unnecessary interventions and maintains safe continuity of care.

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Answer 9

Correct Answers:

"Recurrences may be triggered by stress."

Rationale :

💎Herpes simplex virus type 1 (HSV-1) causes oral herpes, which manifests as painful cold sores or blisters.

💎The virus becomes latent in nerve ganglia and can be reactivated by stress, illness, fatigue, or immunosuppression.

💎Recurrences are common and vary in frequency among individuals.

💎Antiviral medications can reduce severity and duration of outbreaks but do not eliminate the virus.

💎Teaching the client about triggers and prevention helps reduce recurrences and transmission.

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Answer 10

Correct Answers:

The client is a pack-a-day smoker for the last ten years.

Rationale :

🔥Cigarette smoking is one of the strongest risk factors for peptic ulcer disease because it increases gastric acid secretion, reduces mucosal healing, and interferes with H. pylori treatment.

🔥Chronic smoking also worsens complications such as GI bleeding and perforation.

🔥Compared to exercise, caffeine use, or ibuprofen allergy, smoking presents the greatest concern because of its direct role in ulcer persistence and recurrence.

🔥Long-term tobacco use also increases risk for gastric cancer in ulcer patients.

🔥Counseling and support for smoking cessation are essential parts of care.

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QLexNursing

1 :
Drag and drop the clients who should be considered as potential candidates for tissue plasminogen activator (IPA).

3 :
A client with deep vein thrombosis (DVT) experiences acute chest pain and dyspnea. Which action is a nursing priority?

4 :
A nurse is caring for a client in renal failure who has an arteriovenous (AV) fistula for hemodialysis. Prior to hemodialysis, the nurse should evaluate the fistula for which finding as evidence that it is patent?

5 :
An older adult client is seen in the clinic and the nurse discusses influenza prevention. Select whether each teaching item should be included or not included in the teaching plan.

6 :
The client admitted with herpes zoster (shingles) asks the nurse, "What causes shingles?" Which response by the nurse is most appropriate?

7 :
The older client is being monitored for a myocardial infarction. What atypical sign should the nurse monitor for?

8 :
The doctor orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 0800: 60 mL; 0900: 70 mL. Based on these amounts, which action should the nurse take?

9 :
A client in the clinic is diagnosed with herpes simplex virus type 1. Which statement should the nurse include when educating the client?

10 :
The nurse reviews the electronic health record for a client diagnosed with peptic ulcers. Which information is most concerning to the nurse?

QLexNursing

1 : Drag and drop the clients who should be considered as potential candidates for tissue plasminogen activator (IPA).

3 : A client with deep vein thrombosis (DVT) experiences acute chest pain and dyspnea. Which action is a nursing priority?

4 : A nurse is caring for a client in renal failure who has an arteriovenous (AV) fistula for hemodialysis. Prior to hemodialysis, the nurse should evaluate the fistula for which finding as evidence that it is patent?

5 : An older adult client is seen in the clinic and the nurse discusses influenza prevention. Select whether each teaching item should be included or not included in the teaching plan.

6 : The client admitted with herpes zoster (shingles) asks the nurse, "What causes shingles?" Which response by the nurse is most appropriate?

7 : The older client is being monitored for a myocardial infarction. What atypical sign should the nurse monitor for?

8 : The doctor orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 0800: 60 mL; 0900: 70 mL. Based on these amounts, which action should the nurse take?

9 : A client in the clinic is diagnosed with herpes simplex virus type 1. Which statement should the nurse include when educating the client?

10 : The nurse reviews the electronic health record for a client diagnosed with peptic ulcers. Which information is most concerning to the nurse?

1 :
Drag and drop the clients who should be considered as potential candidates for tissue plasminogen activator (IPA).

3 :
A client with deep vein thrombosis (DVT) experiences acute chest pain and dyspnea. Which action is a nursing priority?

4 :
A nurse is caring for a client in renal failure who has an arteriovenous (AV) fistula for hemodialysis. Prior to hemodialysis, the nurse should evaluate the fistula for which finding as evidence that it is patent?

5 :
An older adult client is seen in the clinic and the nurse discusses influenza prevention. Select whether each teaching item should be included or not included in the teaching plan.

6 :
The client admitted with herpes zoster (shingles) asks the nurse, "What causes shingles?" Which response by the nurse is most appropriate?

7 :
The older client is being monitored for a myocardial infarction. What atypical sign should the nurse monitor for?

8 :
The doctor orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 0800: 60 mL; 0900: 70 mL. Based on these amounts, which action should the nurse take?

9 :
A client in the clinic is diagnosed with herpes simplex virus type 1. Which statement should the nurse include when educating the client?

10 :
The nurse reviews the electronic health record for a client diagnosed with peptic ulcers. Which information is most concerning to the nurse?