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 C
Explanation
Choice A reason: Puffed rice cereal lacks significant fiber, offering minimal bulk to stimulate peristalsis. It’s a poor choice for constipation relief, as it doesn’t soften stool or aid movement.
Choice B reason: Tomato juice provides hydration and some nutrients, but its low fiber content doesn’t effectively combat constipation. High-fiber foods are needed to increase stool bulk instead.
Choice C reason: Bran muffins are high in insoluble fiber, adding bulk and water to stool, promoting bowel movements. This choice reflects understanding of constipation management through diet.
Choice D reason: Cottage cheese is low in fiber, offering protein but no relief for constipation. It doesn’t enhance intestinal motility or stool consistency, making it an ineffective option.
Correct Answer is A
Explanation
Choice A reason: Remeasuring confirms the 190/110 mm Hg reading, ensuring accuracy in kidney failure, where hypertension is common. It’s the first step before acting.
Choice B reason: Administering medication without verification risks error; BP may be inaccurate. In kidney failure, precise BP guides therapy, so this waits.
Choice C reason: Reporting to the charge nurse follows confirmation; unverified readings waste time. Accuracy in chronic kidney failure is critical before escalating.
Choice D reason: Bed rest may help, but confirming BP first prioritizes data. Kidney failure needs validated hypertension readings to direct immediate care safely.
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