Medical-Surgical Nursing Flashcards

A patient with acute MI is prescribed streptokinase. Which finding is an absolute contraindication to thrombolytic therapy?

Answer: Recent intracranial surgery within 3 months

Recent intracranial surgery, stroke, or head trauma within 3 months is an absolute contraindication to thrombolytic therapy due to the high risk of intracranial hemorrhage. Other absolute contraindications include active internal bleeding and known intracranial neoplasm.

The nurse is assessing a patient for compartment syndrome after a tibial fracture. Which finding is the earliest indicator?

Answer: Pain out of proportion to the injury that is unrelieved by analgesics

The earliest sign of compartment syndrome is pain that is disproportionate to the injury and not relieved by analgesics — often described as deep, burning, and unrelenting. The 6 P's (pain, pressure, paresthesia, pallor, paralysis, pulselessness) develop progressively, with pain first.

A nurse is caring for a patient with severe burns covering 36% of total body surface area (TBSA). Using the Parkland formula, how much lactated Ringer's solution should be given in the first 8 hours?

Answer: Half of the calculated 24-hour volume

The Parkland formula is 4 mL × kg × % TBSA burned = total volume for 24 hours. Half is given in the first 8 hours (from time of injury), and the remaining half over the next 16 hours. This front-loading addresses the initial massive fluid shift.

A patient with myasthenia gravis is in crisis. What distinguishes a myasthenic crisis from a cholinergic crisis?

Answer: Myasthenic crisis improves with edrophonium (Tensilon test); cholinergic crisis worsens

The Tensilon (edrophonium) test differentiates the two crises: myasthenic crisis (under-medication) improves with edrophonium because it increases acetylcholine. Cholinergic crisis (over-medication with anticholinesterases) worsens with edrophonium.

The nurse is caring for a patient with cirrhosis who develops asterixis (liver flap). This finding indicates:

Answer: Hepatic encephalopathy

Asterixis (flapping tremor of the hands) is a classic sign of hepatic encephalopathy caused by accumulation of ammonia and other toxins that the failing liver cannot clear. It indicates significant neurological impairment from hepatocellular failure.

Which intervention is the priority for a patient admitted with acute ischemic stroke within 2 hours of symptom onset?

Answer: Assess eligibility for IV alteplase (tPA) thrombolysis

For acute ischemic stroke within 4.5 hours of onset, IV alteplase (tPA) is the primary intervention if the patient meets eligibility criteria. CT without contrast is done first to exclude hemorrhage, but the overarching priority is rapid assessment for thrombolysis (time is brain).