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 B
Explanation
Choice A reason: Cardiac medications don’t contraindicate varicella vaccine, a live virus. Unless immunocompromised (e.g., via steroids), cardiac conditions don’t impair immunity enough for risk. Scientifically, this lacks evidence as a barrier, as the vaccine’s safety profile supports use in stable cardiac cases without immune suppression.
Choice B reason: Chemotherapy suppresses immunity, making live vaccines like varicella dangerous due to risk of unchecked viral replication. This contraindication is scientifically grounded, as immunocompromised states (e.g., from cancer treatment) heighten infection risk, necessitating delay until immune recovery per vaccination guidelines.
Choice C reason: Two diarrhea stools in a day isn’t a contraindication unless severe or linked to immunosuppression. Mild illness doesn’t preclude live vaccines; varicella can be given unless fever or systemic compromise exists. Scientifically, this is insufficient to halt immunization based on current evidence.
Choice D reason: Clear rhinorrhea from a cold isn’t a contraindication for varicella vaccine. Mild respiratory symptoms without fever don’t impair immune response significantly. Scientifically, guidelines allow vaccination during minor illnesses, as it poses no increased risk, distinguishing it from severe immune deficits.
Correct Answer is B
Explanation
Choice A reason: Mouthing objects is normal at 4 months, aiding exploration and teething. It’s developmentally appropriate, not requiring provider notification at this stage.
Choice B reason: Anterior fontanel closure before 9-18 months may signal craniosynostosis, affecting brain growth. This premature finding warrants urgent provider evaluation.
Choice C reason: Rolling back to abdomen is a 4-6-month milestone, expected here. It’s a healthy motor development sign, not needing provider attention.
Choice D reason: Posterior fontanel often closes by 2-3 months, normal at 4 months. This aligns with typical infant skull development, not a concern.
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