Practice Quiz

CMSRN Medical-Surgical Nursing

Category - Neuro/Muscular

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Mrs. Lambert, 68 years old, is admitted for a recent onset (less than 2 hours) of left hemiparesis, facial droop, field cut, and an imaging report indicating a positive computed tomography (CT) scan of the head. The nurse knows that this indicates:
  1. A hemorrhagic brain attack. The client should receive a thrombolytic agent.
  2. An ischemic brain attack. The client should have a thrombolytic agent.
  3. A hemorrhagic brain attack. The client should not receive a thrombolytic agent.
  4. An ischemic brain attack. The client should not receive a thrombolytic agent.
Explanation
Answer - C - A positive CT of the head indicates hemorrhage. A thrombolytic agent is contraindicated in hemorrhage because it causes bleeding, increases the size of the hemorrhagic brain attack, and can cause death. An ischemic brain attack would not be visualized on a CT scan until approximately 12-24 hours after the initial brain injury, when the infarcted and ischemic tissues can be visualized as gray-colored changes on the brain scan.
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