A nurse is caring for a client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?
Epigastric pain
Seizure activity
Sudden loss of vision in one eye
Pain radiating down the left arm
The Correct Answer is C
Choice A reason: Epigastric pain suggests GI issues, not TIAs. In hypertension, TIAs affect cerebral vessels, causing neurological deficits, not abdominal symptoms like this.
Choice B reason: Seizures stem from cortical irritation, not typical TIA vascular occlusion. Hypertension-related TIAs produce transient deficits, not convulsive activity usually.
Choice C reason: Sudden monocular vision loss (amaurosis fugax) is a classic TIA sign in hypertension. It reflects temporary retinal artery occlusion, resolving quickly.
Choice D reason: Left arm pain mimics cardiac issues, not TIAs. Hypertension TIAs target brain circulation, causing focal deficits, not referred pain patterns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Dark red urine signals active bleeding post-TURP, beyond expected light pink. It may indicate hemorrhage, requiring urgent provider intervention to prevent complications.
Choice B reason: 300 mL over 8 hr is adequate output post-TURP, not alarming. It aligns with expected bladder irrigation effects, needing no immediate report.
Choice C reason: Small clots are normal post-TURP as the prostate heals. Only large or persistent clots warrant concern, so this is an expected finding.
Choice D reason: Frequent urination urge is common post-TURP from bladder irritation. It’s not critical unless paired with obstruction, so it doesn’t need reporting.
Correct Answer is B
Explanation
Choice A reason: Notifying the provider follows assessment; vital signs gauge injury first. Immediate stability check precedes communication in a fall scenario like this.
Choice B reason: Measuring vital signs first assesses for shock, injury, or distress post-fall. It’s the priority to ensure safety before further actions in emergencies.
Choice C reason: Documentation is essential but secondary to client stability. Vital signs determine urgency, so recording waits until immediate health risks are evaluated.
Choice D reason: Incident reports address safety trends, not acute care. Assessing vital signs first ensures the client’s condition guides subsequent reporting and intervention.
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