Question

A nurse is caring for a client who received thrombolytic medication following an ischemic stroke. What is the primary purpose of this course of therapy?

Answer 1

Correct Answers:

Restore blood flow by breaking down clots

Rationale :

💠 The primary goal is rapid reperfusion of ischemic brain tissue, limiting the area of infarction.

💠 Restoring blood flow helps preserve the ischemic penumbra, the area of brain tissue that is salvageable if circulation is quickly reestablished.

💠 Early clot dissolution reduces long-term neurologic deficits and improves functional outcomes.

💠 Time sensitivity is critical, as thrombolytics are most effective when given within the therapeutic window (generally within 3–4.5 hours of symptom onset).

💠 Decreasing intracranial bleeding is not the purpose; in fact, bleeding is a major risk of thrombolytic therapy.

💠 Narrowing blood vessels or reducing inflammation are not the mechanisms of thrombolytics; their action is specifically fibrinolytic (clot-dissolving).

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Answer 2

Correct Answers:

A client returning from an angiogram with balloon angioplasty

Rationale :

🔷 A client returning from angioplasty is at high risk for acute bleeding or arterial complications at the catheter insertion site.

🔷 Immediate assessment focuses on the femoral site, checking for hematoma, active bleeding, swelling, or firmness.

🔷 Distal pulses, skin color, temperature, and capillary refill must be evaluated to ensure adequate perfusion.

🔷 Vital signs must be monitored closely for hypotension or tachycardia, which may indicate hemorrhage.

🔷 Because complications can occur rapidly, this client takes priority using the circulation (C) component of ABCs.

❌ Controlled atrial fibrillation (HR 88 bpm) – The heart rate is stable and within acceptable range. Controlled atrial fibrillation without instability does not require immediate intervention.

❌ 48 hours post–femoral-popliteal bypass with mild pain – Mild incisional pain at 48 hours post-op is expected. There are no signs of acute vascular compromise described.

❌Liver disease with mild abdominal distention – Mild distention can occur with chronic liver disease (ascites). Without respiratory compromise or acute pain, this is not an immediate priority.

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Answer 3

Correct Answers:

Attempt to locate the pulse using a Doppler device

Rationale :

🔶 The dorsalis pedis pulse is sometimes difficult to palpate due to normal anatomical variation.

🔶 The most appropriate first action is to use a Doppler ultrasound device to confirm arterial blood flow.

🔶 Doppler assessment helps differentiate between true absence of pulse and difficulty palpating.

🔶 Confirming circulation prevents unnecessary escalation.

🔶 Early detection of impaired perfusion helps prevent acute limb ischemia.

❌ Inform the provider immediately – The nurse must first verify absence of pulse with Doppler before notifying the provider.

❌ Listen with a stethoscope – Peripheral pulses are not assessed with a stethoscope. A Doppler device is required to detect faint arterial flow.

❌ Compare with all extremity pulses – Comparison is useful, but confirmation with Doppler is the priority initial action when a pulse is not palpable.

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Answer 4

Correct Answers:

Having a first-degree relative diagnosed with Bipolar I disorder

Rationale :

🔵 Genetic predisposition is one of the strongest risk factors for Bipolar I disorder.

🔵 Having a first-degree relative significantly increases lifetime risk.

🔵 Bipolar I is characterized by at least one episode of mania, often alternating with depression.

🔵 Family history plays a larger role than situational stress alone.

🔵 Early identification of genetic risk supports early monitoring and intervention.

❌ Stable relationships and occupational functioning – This reflects healthy psychosocial functioning and is not a risk factor.

❌ Occasional mild mood swings from stress – Situational mood fluctuations are common and do not indicate Bipolar I disorder.

❌ Chronic low-grade depression – This is more consistent with persistent depressive disorder, not Bipolar I, which requires a manic episode for diagnosis.

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Answer 5

Correct Answers:

Recent suicide attempt with a detailed current plan

Rationale :

🔴 A recent suicide attempt is one of the strongest predictors of future suicide, especially within the first weeks to months after the attempt.

🔴 The presence of a detailed current plan indicates high lethality risk because it demonstrates preparation and intent.

🔴 Suicide risk escalates significantly when there is a combination of plan, means, intent, and prior attempt.

🔴 This situation requires immediate safety interventions, including constant observation and possible hospitalization.

🔴 According to priority frameworks, an active plan with prior attempt represents an imminent threat to life, making it the highest-risk scenario.

❌ Verbalizing hopelessness without a plan – Hopelessness is a serious warning sign, but without a plan or prior attempt, it reflects elevated risk rather than immediate imminent danger.

❌ Social withdrawal and poor appetite – These are symptoms of depression and indicate vulnerability, but they do not represent acute suicidal intent.

❌ History of depression and recent job loss – These are significant risk factors; however, they are predisposing factors and do not indicate immediate action is underway.

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Answer 6

Correct Answers:

Having unprotected vaginal intercourse with a partner who is living with HIV

Rationale :

🟢 Unprotected vaginal intercourse is one of the primary routes of HIV transmission because the virus spreads through exchange of infected body fluids, including blood, semen, vaginal secretions, and rectal fluids.

🟢 The vaginal mucosa provides a direct entry point into the bloodstream, increasing transmission risk when protection is not used.

🟢 Absence of barrier protection (such as condoms) significantly increases exposure risk.

🟢 Even if a partner is on antiretroviral therapy, risk depends on whether the viral load is undetectable; without confirmed viral suppression, transmission remains possible.

🟢 Sexual contact without protection is consistently identified as the highest behavioral risk factor in community transmission.

❌ Sharing eating utensils does not transmit HIV because the virus is not spread through saliva in casual contact.

❌ Using public restrooms poses no risk, as HIV does not survive on surfaces and is not transmitted by environmental contact.

❌ Kissing on the cheek does not transmit HIV because there is no exchange of infected body fluids.

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Answer 7

Correct Answers:

Supine: 128/70 mmHg, 70 bpm Sitting: 102/64 mmHg, 86 bpm Standing: 100/60 mmHg, 92 bpm

Rationale :

🔵 Orthostatic hypotension is defined as a drop in systolic blood pressure ≥20 mmHg or diastolic ≥10 mmHg within 3 minutes of standing, often accompanied by an increase in heart rate.

🔵 In option A, the systolic pressure drops from 128 mmHg (supine) to 100 mmHg (standing) — a 28 mmHg decrease, which meets diagnostic criteria.

🔵 The heart rate increases from 70 bpm to 92 bpm, showing a compensatory tachycardic response to decreased cerebral perfusion.

🔵 Post-stroke clients on metoprolol are at risk because beta-blockers reduce sympathetic compensation.

🔵 Identifying this pattern is critical to prevent falls, syncope, and injury, especially in neurologically vulnerable patients.

❌ Option B shows minimal systolic change (101 to 98 mmHg), which does not meet the ≥20 mmHg drop criteria.

❌ Option C demonstrates stable blood pressure readings without significant positional change.

❌ Option D shows very small positional variations, which are within normal physiologic adjustment.

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Answer 8

Correct Answers:

Hemoglobin

Rationale :

🟣 Epoetin alfa is an erythropoiesis-stimulating agent that increases red blood cell production by stimulating the bone marrow.

🟣 The primary laboratory value monitored before administration is hemoglobin (Hgb) because excessive elevation increases the risk of thromboembolic events.

🟣 If hemoglobin is significantly elevated (generally >11 g/dL in chronic kidney disease), the dose should be held or adjusted.

🟣 Elevated hemoglobin increases blood viscosity, raising the risk of stroke, myocardial infarction, and hypertension.

🟣 Safe administration requires careful trending of Hgb levels to avoid overcorrection of anemia.

❌ Blood urea nitrogen (BUN) reflects renal function but does not determine whether epoetin alfa should be held for safety.

❌ Prothrombin time evaluates clotting pathway function; epoetin does not directly alter coagulation factors.

❌ Sodium levels are unrelated to erythropoiesis and do not influence epoetin dosing decisions.

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Answer 9

Correct Answers:

The client states, "I don't see the point in doing therapy anymore."

Rationale :

🔶 The statement “I don't see the point in doing therapy anymore” reflects hopelessness and loss of motivation, which are hallmark warning signs of post-stroke depression.

🔶 Post-stroke depression commonly occurs within weeks to months after a cerebrovascular event due to both neurochemical changes and psychological adjustment.

🔶 Expressing lack of purpose or benefit in therapy suggests withdrawal from recovery efforts, which can significantly impair rehabilitation outcomes.

🔶 This type of statement may indicate emerging suicidal ideation or severe depressive symptoms, requiring prompt provider notification.

🔶 Early identification and treatment (antidepressants, counseling, support) improves functional recovery and quality of life.

❌ Expressing frustration about needing assistance is a normal adjustment response during recovery and does not alone indicate clinical depression.

❌ Feeling tired after rehabilitation sessions is expected due to increased physical and cognitive demands during therapy.

❌ Becoming tearful when discussing limitations is a common emotional reaction to loss of function and does not necessarily signal major depressive disorder.

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Answer 10

Correct Answers:

Lithium

Rationale :

🔷 Lithium is a first-line mood stabilizer used in the treatment of Bipolar I disorder, particularly for managing acute mania and preventing recurrent episodes.

🔷 It helps stabilize mood by modulating neurotransmitters such as dopamine and serotonin, reducing manic symptoms.

🔷 Lithium is effective for both acute manic episodes and long-term maintenance therapy.

🔷 It has strong evidence in reducing suicide risk in individuals with bipolar disorder.

🔷 Close monitoring of serum lithium levels (0.6–1.2 mEq/L) is required to prevent toxicity.

❌ Haloperidol is an antipsychotic that may be used short-term for severe agitation or psychosis but is not the primary maintenance medication for Bipolar I disorder.

❌ Lorazepam is a benzodiazepine used for acute anxiety or agitation; it does not stabilize mood long term.

❌ Sertraline is an SSRI antidepressant and may precipitate mania if used alone in Bipolar I disorder.

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QLexNursing

1 :
A nurse is caring for a client who received thrombolytic medication following an ischemic stroke. What is the primary purpose of this course of therapy?

2 :
A nurse is beginning a shift and reviews the client assignments. Which client requires immediate assessment?

3 :
During a vascular assessment, the nurse cannot feel a client's dorsalis pedis pulse on the left foot. What is the most appropriate initial nursing action?

4 :
A nurse is collecting a psychosocial history for a newly admitted client. Which finding should the nurse recognize as a risk factor for developing Bipolar I disorder?

5 :
A nurse is evaluating a client's suicide risk. Which of the following findings represents the greatest immediate risk for suicide?

6 :
During a community education session about human immunodeficiency virus (HIV) a client asks which behavior poses the greatest risk for transmission of HIV. The nurse should identify which behavior is the highest risk?

7 :
A nurse is caring for a client who is five (5) days post-ischemic stroke who has been prescribed metoprolol 50 mg po daily and atorvastatin 20 mg po daily. Which set of vital signs alerts the nurse that the client has orthostatic hypotension

8 :
A client is prescribed epoetin alfa three times per week. Before administering the medication, the nurse reviews the client's laboratory results. Which laboratory value, if significantly elevated, should make the nurse question administering the dose?

9 :
A nurse is caring for a client who experienced a stroke two (2) weeks ago. Which finding would be most concerning for post-stroke depression and should be reported to the primary healthcare provider?

10 :
A nurse is caring for a client who is being treated with Bipolar I disorder. What medication does the nurse anticipate being prescribed?

QLexNursing

1 : A nurse is caring for a client who received thrombolytic medication following an ischemic stroke. What is the primary purpose of this course of therapy?

2 : A nurse is beginning a shift and reviews the client assignments. Which client requires immediate assessment?

3 : During a vascular assessment, the nurse cannot feel a client's dorsalis pedis pulse on the left foot. What is the most appropriate initial nursing action?

4 : A nurse is collecting a psychosocial history for a newly admitted client. Which finding should the nurse recognize as a risk factor for developing Bipolar I disorder?

5 : A nurse is evaluating a client's suicide risk. Which of the following findings represents the greatest immediate risk for suicide?

6 : During a community education session about human immunodeficiency virus (HIV) a client asks which behavior poses the greatest risk for transmission of HIV. The nurse should identify which behavior is the highest risk?

7 : A nurse is caring for a client who is five (5) days post-ischemic stroke who has been prescribed metoprolol 50 mg po daily and atorvastatin 20 mg po daily. Which set of vital signs alerts the nurse that the client has orthostatic hypotension

8 : A client is prescribed epoetin alfa three times per week. Before administering the medication, the nurse reviews the client's laboratory results. Which laboratory value, if significantly elevated, should make the nurse question administering the dose?

9 : A nurse is caring for a client who experienced a stroke two (2) weeks ago. Which finding would be most concerning for post-stroke depression and should be reported to the primary healthcare provider?

10 : A nurse is caring for a client who is being treated with Bipolar I disorder. What medication does the nurse anticipate being prescribed?

1 :
A nurse is caring for a client who received thrombolytic medication following an ischemic stroke. What is the primary purpose of this course of therapy?

2 :
A nurse is beginning a shift and reviews the client assignments. Which client requires immediate assessment?

3 :
During a vascular assessment, the nurse cannot feel a client's dorsalis pedis pulse on the left foot. What is the most appropriate initial nursing action?

4 :
A nurse is collecting a psychosocial history for a newly admitted client. Which finding should the nurse recognize as a risk factor for developing Bipolar I disorder?

5 :
A nurse is evaluating a client's suicide risk. Which of the following findings represents the greatest immediate risk for suicide?

6 :
During a community education session about human immunodeficiency virus (HIV) a client asks which behavior poses the greatest risk for transmission of HIV. The nurse should identify which behavior is the highest risk?

7 :
A nurse is caring for a client who is five (5) days post-ischemic stroke who has been prescribed metoprolol 50 mg po daily and atorvastatin 20 mg po daily. Which set of vital signs alerts the nurse that the client has orthostatic hypotension

8 :
A client is prescribed epoetin alfa three times per week. Before administering the medication, the nurse reviews the client's laboratory results. Which laboratory value, if significantly elevated, should make the nurse question administering the dose?

9 :
A nurse is caring for a client who experienced a stroke two (2) weeks ago. Which finding would be most concerning for post-stroke depression and should be reported to the primary healthcare provider?

10 :
A nurse is caring for a client who is being treated with Bipolar I disorder. What medication does the nurse anticipate being prescribed?