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?

The client should maintain systolic BP between 120 and 129 mm Hg.

The client should maintain systolic BP between 130 and 135 mm Hg.

The client should maintain systolic BP between 136 and 140 mm Hg.

The client should maintain systolic BP between 141 and 145 mm Hg.

Note the time the seizure started

Answer and Explanation

The Correct Answer is A

A. The client should maintain systolic BP between 120 and 129 mm Hg.

This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.

B. The client should maintain systolic BP between 130 and 135 mm Hg.

This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.

C. The client should maintain systolic BP between 136 and 140 mm Hg.

This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.

D. The client should maintain systolic BP between 141 and 145 mm Hg.

This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.

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

Explanation

A. Muscle tremors:

Muscle tremors, particularly resting tremors, are a hallmark feature of Parkinson's disease. These tremors typically occur in the hands, fingers, arms, legs, jaw, or head and may worsen with stress or inactivity.

B. Slow body movement (bradykinesia):

Bradykinesia refers to slowness of movement and is another key symptom of Parkinson's disease. Patients may have difficulty initiating movement, experience a decrease in spontaneous movement (hypokinesia), and demonstrate reduced range of motion.

C. Rigidity:

Rigidity, or stiffness of the muscles, is a common symptom of Parkinson's disease. It often affects the limbs and trunk and can contribute to difficulty with movement and posture.

D. Pill rolling:

Pill rolling refers to a specific type of tremor characterized by rhythmic, rolling movements of the thumb and fingers, resembling the action of rolling a pill between the fingers and thumb. This tremor is commonly seen in Parkinson's disease.

E. Lack of facial expression:

Parkinson's disease can lead to a reduced range of facial expressions, also known as hypomimia or "masked facies." Patients may have a fixed, expressionless facial appearance and reduced blinking.

F. Drooling:

Drooling, or excessive salivation, can occur in Parkinson's disease due to impaired swallowing function (dysphagia) and reduced control over oral and facial muscles.

A. adventitious breath sounds B. weak pulse C. hypotension D. poor skin turgor

Correct Answer is A

Explanation

A. Adventitious breath sounds:

Adventitious breath sounds refer to abnormal lung sounds heard upon auscultation of the chest. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. In the context of fluid volume excess, particularly in the acute phase of a cerebrovascular accident (CVA) or stroke, adventitious breath sounds such as crackles are indicative of pulmonary edema. Pulmonary edema occurs when there is an excessive accumulation of fluid in the lungs, impairing gas exchange and leading to symptoms such as shortness of breath and respiratory distress.

B. Weak pulse:

A weak pulse may suggest poor perfusion or decreased cardiac output rather than fluid volume excess. While decreased cardiac output can be a consequence of heart failure, which may be associated with fluid volume excess, a weak pulse is not a direct indicator of fluid overload. In the acute phase of a CVA, a weak pulse may prompt further assessment for other cardiovascular complications or neurogenic shock.

C. Hypotension:

Hypotension, or low blood pressure, is not typically associated with fluid volume excess. Instead, hypotension may indicate hypovolemia, shock, or other underlying cardiovascular conditions. While hypotension can occur secondary to severe heart failure or fluid overload in some cases, it is not a direct indicator of fluid volume excess in the acute phase of a CVA.

D. Poor skin turgor:

Poor skin turgor is a clinical finding associated with dehydration rather than fluid volume excess. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. In contrast, fluid volume excess is characterized by edema, which may manifest as pitting or non-pitting edema, rather than poor skin turgor. However, in fluid volume excess, the skin may appear stretched or taut due to the accumulation of fluid in the interstitial spaces.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Parkinson's disease has which characteristic symptom(s)? SELECT ALL THAT APPLY

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

Explanation

The assessment that indicates a fluid volume excess in a patient in the acute phase of a CVA is:

Correct Answer is A

Explanation

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