A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete?(Select All that Apply.)

Muscle strength

Facial symmetry

Peripheral pulses

Vision changes

Aphasia

Answer and Explanation

Correct Answer : A,B,D

Choice A Reason:

Muscle strength is correct. Assessing muscle strength is essential to determine if there are any neurological deficits or weakness that could indicate a neurological condition or injury. Sudden falls can be indicative of various neurological issues, such as stroke or transient ischemic attack (TIA). Assessing muscle strength helps identify any motor impairments or weakness that could contribute to the fall.

Choice B Reason:

Facial symmetry is correct. Assessing facial symmetry is crucial to identify any signs of facial droop, which could indicate a neurological deficit such as a stroke or Bell's palsy. Facial asymmetry may suggest damage to the facial nerve or other neurological issues.

Choice C Reason:

Peripheral pulses is incorrect. While assessing peripheral pulses is important for evaluating circulation, it may not be the priority assessment in this scenario where the client has suddenly fallen and may be experiencing neurological symptoms. Neurological deficits, such as weakness or changes in facial symmetry, vision, or speech, are more indicative of acute neurological issues like stroke or transient ischemic attack (TIA), which require immediate attention and intervention. In emergency situations, prioritizing assessments related to potential life-threatening conditions such as neurological deficits takes precedence over assessing peripheral pulses.

Choice D Reason:

Vision changes is correct. Assessing for vision changes is important to identify any visual disturbances or deficits that could contribute to falls or indicate underlying neurological issues such as a stroke or transient ischemic attack (TIA). Visual disturbances may include blurriness, double vision, or loss of vision in one or both eyes.

Choice E Reason:

Aphasia is incorrect. Assessing for aphasia, which is the inability to understand or express speech, is essential to identify any language deficits that could indicate a neurological condition such as a stroke. Aphasia may present as difficulty speaking, understanding language, or both.

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Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A Reason:

Weight control if the client's BMI is greater than 35 is correct. Obesity is a risk factor for cardiovascular disease and can exacerbate symptoms of heart failure. Weight control, particularly if the client's BMI is greater than 35, is important for managing cardiac conditions such as heart failure and reducing the risk of pulmonary edema.

Choice B Reason:

Healthy lifestyle is correct. Adopting a healthy lifestyle, including regular exercise, balanced diet, adequate hydration, and stress management, is essential for managing cardiac conditions and reducing the risk of complications such as pulmonary edema.

Choice C Reason:

Smoking cessation is correct. Smoking is a major risk factor for cardiovascular disease and can worsen heart failure symptoms. Smoking cessation is crucial for managing cardiac conditions and reducing the risk of pulmonary edema and other complications.

Choice D Reason:

Heart disease prevention is correct. Providing information about heart disease prevention strategies, such as maintaining a healthy diet, managing blood pressure and cholesterol levels, regular exercise, and regular medical check-ups, can help reduce the risk of exacerbations and complications in clients with pre-existing cardiac conditions.

Choice E Reason:

Glycemic control if the client is diabetic is correct. Diabetes is a risk factor for cardiovascular disease and can contribute to the development and progression of heart failure. Glycemic control, along with lifestyle modifications and medication management, is important for managing diabetes and reducing the risk of complications such as pulmonary edema.

A. The client should maintain systolic BP between 120 and 129 mm Hg. B. The client should maintain systolic BP between 136 and 140 mm Hg. C. The client should maintain systolic BP between 141 and 145 mm Hg. D. The client should maintain systolic BP between 130 and 135 mm Hg.

Correct Answer is A

Explanation

Choice A Reason:

The client should maintain systolic BP between 120 and 129 mm Hg. This option aligns with current guidelines for blood pressure management following a transient ischemic attack (TIA). Tight blood pressure control is recommended to reduce the risk of recurrent cerebrovascular events, such as stroke. Maintaining systolic blood pressure (SBP) between 120 and 129 mm Hg has been associated with significant risk reduction in stroke recurrence compared to higher blood pressure targets. Therefore, this option reflects the recommended approach for blood pressure management in individuals with a history of TIA.

Choice B Reason:

The client should maintain systolic BP between 136 and 140 mm Hg: This option suggests a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 136 to 140 mm Hg may pose an increased risk of recurrent cerebrovascular events compared to tighter blood pressure control.

Choice C Reason:

The client should maintain systolic BP between 141 and 145 mm Hg. Similarly, this option proposes a systolic blood pressure (SBP) range that is higher than the recommended target for blood pressure management following a TIA. Allowing SBP to remain in the range of 141 to 145 mm Hg may not provide adequate protection against stroke recurrence compared to tighter blood pressure control.

Choice D Reason:

The client should maintain systolic BP between 130 and 135 mm Hg. While this option suggests a systolic blood pressure (SBP) range that is closer to the recommended target compared to options B and C, it still falls slightly above the optimal range for blood pressure management following a TIA. Tighter blood pressure control, ideally below 130 mm Hg, is typically preferred to reduce the risk of recurrent cerebrovascular events.

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A nurse in the emergency department is assessing a client who was brought in by a neighbor after falling down suddenly while walking. Which of the following assessments are the priority for the nurse to complete?(Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following information should the nurse include when educating a client who has pulmonary edema as a result of a pre-existing cardiac condition? (Select All that Apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

Correct Answer is A

Explanation

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