Chapter 45 - Critically Ill Patients with Neurologic Problems

A client who has a severe head injury is placed in a drug-induced coma. The client's husband states, "I do not understand. Why are you putting her into a coma?" How does the nurse respond?

"This medication will decrease the activity of her brain so that additional damage does not occur." When intracranial pressure cannot be controlled by other means, clients may be placed in a barbiturate coma to decrease cerebral metabolic demands, decrease formation of vasogenic edema, and produce a more uniform blood supply to the brain.

The nurse is caring for a client who has a moderate head injury. The client's sister asks, "Will my brother return to his normal functioning level when his brain heals?" How does the nurse respond?

"Your brother may experience many changes in personality and cognitive abilities." Those with moderate to severe head injuries are never the same as before the injury. They can experience changes in cognition such as memory loss, difficulty learning new information, and limited concentration. Personality alterations such as outbursts of temper and depression also may occur.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.)

- A client with a moderate trauma may need hospitalization. - A client with a Glasgow Coma Scale score of 3 has severe TBI. - The terms "mild TBI" and "concussion" have similar meanings. "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)

-Client who exhibits extreme emotional lability -Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 -Client who has a past hospitalization for a suicide attempt -Client who is unable to walk or eat 3 weeks post-stroke Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral.

A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.)

-Discharging the client on a statin medication -Providing and charting stroke education -Preventing venous thromboembolism Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism.

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke?

A 27-year-old heavy cocaine user Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily.

A client with a head injury is being given midazolam (Versed) while on mechanical ventilation. Which action does the nurse implement for this client?

Administer an analgesic. Midazolam (Versed) is a benzodiazepine agent and has no analgesic effect. It should be given with pain medication. This medication does not increase the risk of seizures and does not decrease urinary output. Clients should not be fed when being mechanically ventilated.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)

Alcohol intake High-fat diet Obesity Smoking Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care?

Ambulate only with a gait belt. Ataxia is a gait disturbance. For the client's safety, he or she should have assistance and use a gait belt when ambulating.

The nurse assesses periorbital edema and ecchymosis around both eyes of a client who is 6 hours postoperative for craniotomy. Which intervention does the nurse implement for this client?

Apply an ice pack to the affected area. Periorbital edema and ecchymosis are expected after a craniotomy. The nurse should attempt to increase the client's comfort by reducing the swelling with application of ice.

The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client?

Apply sequential compression stockings. To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently

A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Applying a cool washcloth to the head Assisting the client to a position of comfort Keeping voices soft and soothing Maintaining low lighting in the room

A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best?

Ask the client how long ago the clip was placed. Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination.

The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client?

Ask the family to bring in pictures familiar to the client. For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best?

Assess the client's sodium level. This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level.

A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client?

Assess whether or not the client can write. Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact.

The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic stroke?

Atrial fibrillation Clients with a history of hypertension, heart disease, atrial fibrillation, diabetes, obesity, and hypercoagulopathy are at risk for embolic stroke. The other disorders are not risk factors for an embolic stroke.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate?

Attempt to find the family to sign a consent. The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent.

A client has a subarachnoid bolt. What action by the nurse is most important?

Balancing and recalibrating the device This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the device's accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the device's accuracy is most important.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority?

Call the provider or Rapid Response Team. These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP.

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?

Client in a coma for 2 weeks from a motor vehicle crash In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first?

Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?

Client who has a temperature of 102° F (38.9° C) A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first?

Client with a Glasgow Coma Scale score that was 10 and is now is 8 A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)

Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches Client with an aneurysm clip who states that his family is happy there is no chance of recurrence

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client?

Clopidogrel (Plavix) This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke.

A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer?

Dexmedetomidine (Precedex) Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

The nurse is preparing to administer prescribed mannitol (Osmitrol) to a client with a severe head injury. Which precaution does the nurse take before administering this medication?

Draw up the medication using a filtered needle. Mannitol (Osmitrol) must be drawn up using a filtered needle to eliminate microscopic crystals. Narcan does not reverse the effects of mannitol. Hyperventilation does not affect administration of this drug, and clients can be given mannitol while in a barbiturate-induced coma

A client who had a brain attack was admitted to the intensive care unit yesterday. The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking. What does the nurse do next?

Elevate the back rest to 30 degrees and notify the health care provider. The client is experiencing signs of increased intracranial pressure (ICP). Raising the head of the bed would help decrease ICP. The health care provider should then be notified immediately so that other interventions to reduce ICP can be instituted

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority?

Ensure that informed consent is on the chart. For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best?

Explain that personality changes are common following brain injuries. Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?

Has clear lung sounds on auscultation Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred.

The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client?

Impaired proprioception A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best?

Inform the student that the docusate should be given. Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority?

Notify the Rapid Response Team. This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?

Notify the provider of the findings immediately. This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation.

A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client?

Poor prognosis and cognitive function The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?

Respiratory status Respiratory derangements (e.g., hypoxemia, hypercarbia, alterations in pH) can contribute to secondary brain injury in this scenario. Therefore, the important priority is assessment of respiratory status so that secondary brain injury conditions are avoided.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time?

Risk for acquiring an infection The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client?

The client will need near-total care. This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the client's dependence. The client will need more than cuing to complete tasks.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?

Time of symptom onset The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client.

A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer?

Tissue plasminogen activator The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy.

A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke?

Two episodes of speech difficulties in the last month Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. Two episodes of speech difficulties would correlate with TIAs.

A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions?

Unawareness of the existence of her left side Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side, or the left side. This injury would not have an effect on the client's sight. This is not related to poor motor control or paralysis.

The nurse is planning the discharge of a client who has sustained a moderate head injury and is experiencing personality and behavior changes. The client's wife states, "I am concerned about how different he is. What can I do to help with the transition back to our home?" How does the nurse respond?

"Developing a routine will help provide him with a structured environment." Developing a home routine that provides structure and repetition is recommended because clients with personality and behavior problems respond best to this type of environment. The client's personality and emotional functioning will never return to normal. The client may be aggressive, and family members must be aware of potential client reactions.

The nurse is caring for an 80-year-old client who presented to the emergency department in a coma. Which question does the nurse ask the client's family to help determine whether the coma is related to a brain attack?

"Does your mother drink any alcohol or take any medications?" Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic disturbances, can cause profound changes in level of consciousness (LOC) when accompanied by a brain attack. Alcohol abuse and medication toxicity can be especially problematic in older adults.

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care?

"I know I can take care of all these needs by myself." This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?

"Increased pressure from the abscess can cause seizures." Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse.

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond?

"Most of these types of blood clots come from the heart." An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart.

The nurse is assessing a client who was recently diagnosed with a meningioma. Which statement indicates that the client correctly understands the diagnosis?

"My tumor can be removed, but I can still have damage because of pressure in my brain." Meningiomas arise from the coverings of the brain (the meninges) and are the most common type of benign tumor. This tumor is encapsulated, globular, and well demarcated, and causes compression and displacement of nearby brain tissue. Although complete removal of the tumor is possible, it tends to recur and causes irreversible damage to the brain. The tumor is not treated by chemotherapy or radiation.

The nurse is teaching bladder training to a client who is incontinent after a stroke. Which instruction does the nurse include in this client's teaching?

"Plan to use the commode every 2 hours during the day." To begin a bladder training program, teach the client to use the commode, bedpan, or urinal every 2 hours. If used frequently enough, this will prevent accidents and establish a routine. Fluid intake should be restricted at night, and a Foley catheter should be used only for urine retention. The client should empty his or her bladder when the urge occurs and should not hold the bladder.

A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond?

"Rehabilitation will help you function at the highest level possible." The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The other responses do not answer the client's question appropriately.

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.)

- Is allergic to acetaminophen (Tylenol) - Lives alone and is new in town with no friends - Plans to have a beer and go to bed once home Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that.

A nursing student studying the neurologic system learns which information? (Select all that apply.)

-An aneurysm is a ballooning in a weakened part of an arterial wall. -Intracerebral hemorrhage is bleeding directly into the brain. -Reduced perfusion from vasospasm often makes stroke worse. An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.)

-Assess tube placement per agency policy. -Keep the head of the bed elevated at least 30 degrees. -Listen to lung sounds at least every 4 hours. -Run continuous feedings on a feeding pump. All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.)

Admission can overwhelm the coping mechanisms for older clients. These clients are more susceptible to systemic and wound infections. Other medical conditions can complicate treatment for these clients.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Check and document oxygen saturation every 1 to 2 hours. Position the client supine with the head in a neutral midline position. The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

A client is admitted for evaluation of a cerebral tumor. Which clinical manifestations does the nurse assess this client for?

Hemiplegia Aphasia Behavior changes If the tumor affects the cerebral hemispheres, hemiplegia, aphasia, and behavioral changes are common. Hearing loss and nystagmus are found with brainstem lesions.

The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skull fracture. Which complication of this injury does the nurse monitor for?

Hemorrhage This type of fracture may cause hemorrhage from damage to the internal carotid artery. The other problems are not complications of this injury.

A client has experienced a stroke resulting in damage to Wernicke's area. Which clinical manifestation does the nurse monitor for?

Inability to comprehend spoken words The client with damage to Wernicke's area cannot understand spoken or written words. If the client speaks, the language is meaningless, with the client using made-up words. Damage to Wernicke's area does not cause slurred speech, nor will the client communicate with habitual speech only.

The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications?

Monitor neurologic and vital signs closely to identify early changes in status. Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications.

The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client?

Needs frequent re-orientation This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status.

A client has an intraventricular catheter. What action by the nurse takes priority?

Perform hand hygiene before client care. All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.

The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment?

Place the client in high Fowler's position. Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client?

Rotate the client's meal tray when the client stops eating. This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field.

The nurse notes that the left arm of a client who has experienced a brain attack is in a contracted, fixed position. Which complication of this position does the nurse monitor for in this client?

Shoulder subluxation Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder. Contractures are stiff and immobile—not flaccid. Contractures are not caused by fractures or neglect syndrome.

A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client?

Spontaneous ecchymosis Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools.