Nurse Assessing Year Explained for Students (Easy Guide)

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Original Question

The nurse is assessing a 78-year-old female client admitted with a stroke of recent onset within 2 hours of admission. Vital signs: blood pressure, 150/90 mm Hg; pulse rate, 112 beats/min; respiratory rate, 20 breaths/min; temperature, 100.4°F (38.0°C); pulse oximetry reading, 96% on room air. Audible murmur heard upon auscultation. Client is awake but somewhat lethargic and cannot respond to questions. Exhibiting neurologic deficits and impaired mobility of the left side of the body. The client is being evaluated for tissue plasminogen activator (t-PA) therapy. For each assessment parameter, indicate whether the result indicates that t-PA can be utilized. Assessment Parameter t-PA Therapy Indicated t-PA Therapy Not Indicated international normalized ratio (INR) result of 2.0 NIH Stroke Scale/Score (NIHSS) result of 17 blood pressure reading computed tomograph confirmation of ischemic stroke heart murmur

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