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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Threatening health consequences may escalate resistance in diabetes care. It dismisses feelings, reducing trust, and isn’t therapeutic for addressing refusal effectively.
Choice B reason: Guilt via family impact pressures the client, not exploring reasons. This approach hinders open dialogue, critical for diabetes self-management acceptance.
Choice C reason: Inviting thoughts fosters therapeutic communication, exploring barriers to insulin use. It respects autonomy, building trust essential for diabetes education and compliance.
Choice D reason: "Why" questions can feel confrontational, shutting down discussion. Open-ended inquiry better uncovers motivations in diabetes refusal, avoiding defensiveness.
Correct Answer is B
Explanation
Choice A reason: Blaming assistive personnel is subjective and speculative, not factual documentation. Falls may have multiple causes—mobility or environment—not just slippers. Legally and scientifically, records require objective data, not assumptions, to ensure accurate care planning and avoid liability missteps in clinical reporting.
Choice B reason: Quoting the client’s account provides objective, firsthand data about the fall’s circumstances—loss of balance during transfer. This factual detail aids in assessing risk factors like mobility or weakness, aligning with scientific documentation standards for precision and relevance in medical records.
Choice C reason: Incident reports are separate from medical records; mentioning one here is inappropriate. It’s an administrative action, not clinical data, and risks redundancy. Scientifically, records focus on patient status, not process notes, ensuring clarity for care continuity over procedural documentation.
Choice D reason: "Does not appear" is vague, not definitive, lacking objective findings like "no bruising noted." Documentation requires specific observations for accuracy. Scientifically, imprecise language weakens care planning, as it fails to confirm injury status with measurable evidence needed for clinical decisions.
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