Choice A reason:

This is a correct answer. Alteplase is a thrombolytic agent that dissolves blood clots and restores blood flow to the brain in clients who have an ischemic stroke. It should be administered within 3 to 4.5 hours of symptom onset and after ruling out hemorrhagic stroke.

Choice B reason:

This is an incorrect answer. Mannitol is an osmotic diuretic that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue and into the bloodstream. It is used for clients who have increased ICP due to cerebral edema, not ischemic stroke.

Choice C reason:

This is an incorrect answer. Nimodipine is a calcium channel blocker that prevents vasospasm and improves cerebral blood flow in clients who have a subarachnoid hemorrhage, which is a type of hemorrhagic stroke, not ischemic stroke.

Choice D reason:

This is an incorrect answer. Phenytoin is an anticonvulsant that prevents or treats seizures in clients who have a brain injury or tumor, not ischemic stroke.

Choice A reason:

This is a correct answer. Sudden severe headache is a common symptom of hemorrhagic stroke, which is caused by bleeding into the brain tissue or subarachnoid space. The headache may be described as "the worst headache of my life" or "thunderclap headache".

Choice B reason:

This is an incorrect answer. Facial drooping is a common symptom of ischemic stroke, which is caused by a blockage in a cerebral artery that reduces blood flow to the brain tissue. Facial drooping may affect one side of the face and cause asymmetry or difficulty smiling.

Choice C reason:

This is an incorrect answer. Slurred speech is another common symptom of ischemic stroke, which affects the areas of the brain responsible for language and communication. Slurred speech may also be accompanied by aphasia, which is difficulty understanding or expressing words.

Choice D reason:

This is a correct answer. Nuchal rigidity is a common symptom of subarachnoid hemorrhage, which is a type of hemorrhagic stroke that involves bleeding into the space between the brain and the meninges. Nuchal rigidity refers to stiffness or pain in the neck when flexing or extending it.

Choice E reason:

This is a correct answer. Hemiparesis is a common symptom of both ischemic and hemorrhagic stroke, which affect the motor areas of the brain and cause weakness or paralysis on one side of the body. Hemiparesis may affect the face, arm, leg, or trunk on the opposite side of the brain injury.

Choice A reason:

This is an incorrect answer. Elevated troponin level is not a finding that indicates atrial fibrillation as the cause of ischemic stroke. Troponin is a cardiac enzyme that is released into the bloodstream when there is damage to the heart muscle, such as in myocardial infarction (MI) or heart failure. Troponin level may be elevated in some clients who have ischemic stroke due to concurrent cardiac conditions, but it does not indicate the source of embolism.

Choice B reason:

This is a correct answer. Elevated D-dimer level is a finding that indicates atrial fibrillation as the cause of ischemic stroke. D-dimer is a protein fragment that is produced when a blood clot is dissolved by fibrinolysis. D-dimer level may be elevated in clients who have ischemic stroke due to embolism from atrial fibrillation, which is an irregular and rapid heart rhythm that causes poor blood flow and clot formation in the atria.

Choice C reason:

This is an incorrect answer. Elevated C-reactive protein level is not a finding that indicates atrial fibrillation as the cause of ischemic stroke. C-reactive protein is an inflammatory marker that is produced by the liver in response to infection, inflammation, or tissue injury. C-reactive protein level may be elevated in clients who have ischemic stroke due to various causes, but it does not indicate the source of embolism.

Choice D reason:

This is an incorrect answer. Elevated INR is not a finding that indicates atrial fibrillation as the cause of ischemic stroke. INR is a measure of how long it takes for blood to clot, which reflects the effect of anticoagulant medications such as warfarin. INR may be elevated in clients who have ischemic stroke due to anticoagulant therapy, but it does not indicate the source of embolism.

Choice A reason:

This is an incorrect answer. Elevating the head of the bed to 30 degrees is not an appropriate intervention for a client who has a hemorrhagic stroke. Elevating the head of the bed can lower blood pressure and reduce cerebral perfusion pressure, which can worsen brain ischemia and injury.

Choice B reason:

This is an incorrect answer. Administering aspirin as prescribed is not an appropriate intervention for a client who has a hemorrhagic stroke. Aspirin is an antiplatelet agent that inhibits

the clotting of blood and increases the risk of bleeding in the brain or elsewhere. Aspirin is contraindicated for clients who have a hemorrhagic stroke and may worsen their condition.

Choice C reason:

This is a correct answer. Monitoring blood pressure and keeping it within normal range is an appropriate intervention for a client who has a hemorrhagic stroke. Blood pressure is a major factor that affects the severity and outcome of hemorrhagic stroke. High blood pressure can increase the bleeding and ICP, while low blood pressure can reduce cerebral perfusion and oxygenation. The nurse should monitor blood pressure frequently and administer antihypertensive or vasopressor medications as prescribed to maintain optimal blood pressure.

Choice D reason:

This is an incorrect answer. Performing passive range of motion exercises is not an appropriate intervention for a client who has a hemorrhagic stroke. Passive range of motion exercises can increase ICP and bleeding by stimulating the sympathetic nervous system, which increases blood pressure and cerebral blood flow. The nurse should avoid any activity that can increase ICP or bleeding in the acute phase of hemorrhagic stroke.

Choice A reason:

This is a correct answer. The nurse should explain to the client that they need to take medication to prevent blood clots from forming in their arteries after a TIA. A TIA is caused by a temporary blockage in a cerebral artery that reduces blood flow to the brain tissue and causes stroke-like symptoms that resolve within 24 hours. However, a TIA increases the risk of having a full-blown ischemic stroke in the future, which can cause permanent brain damage or death. Therefore, antiplatelet or anticoagulant medications are prescribed to prevent clot formation and reduce stroke risk.

Choice B reason:

This is an incorrect answer. The nurse should not tell the client that they need to take medication to reduce the swelling in their brain after a stroke. This is not the purpose of medication therapy for a TIA. A TIA does not cause significant swelling or edema in the brain, unlike a hemorrhagic stroke, which involves bleeding into the brain tissue or subarachnoid space. Swelling in the brain can increase intracranial pressure (ICP) and cause further brain damage or herniation.

Choice C reason:

This is an incorrect answer. The nurse should not tell the client that they need to take medication to lower their blood pressure and cholesterol levels. This is not the immediate purpose of medication therapy for a TIA, although it may be part of the long-term management of stroke risk factors. High blood pressure and high cholesterol are common causes of atherosclerosis, which is the buildup of plaque in the arterial walls that narrows the lumen and reduces blood flow. Atherosclerosis can lead to ischemic stroke if a piece of plaque breaks off and blocks a cerebral artery.

Choice D reason:

This is an incorrect answer. The nurse should not tell the client that they need to take medication to control their blood sugar and prevent diabetes. This is not the immediate purpose of medication therapy for a TIA, although it may be part of the long-term management of stroke risk factors. High blood sugar and diabetes are common causes of endothelial dysfunction, which is the impairment of the inner lining of the blood vessels that regulates blood flow and clotting. Endothelial dysfunction can lead to ischemic stroke if a blood clot forms and blocks a cerebral artery.