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 D

Explanation

A. Polyuria:

Polyuria, or increased urine output, is not typically associated with increased intracranial pressure. It may occur due to other factors such as diabetes insipidus or fluid administration.

B. Battle's sign:

Battle's sign refers to bruising behind the ear and is often associated with basilar skull fractures. While it can indicate a head injury, it is not a direct manifestation of increased intracranial pressure.

C. Nuchal rigidity:

Nuchal rigidity, stiffness of the neck muscles, is commonly associated with meningitis rather than increased intracranial pressure. It is a sign of meningeal irritation and inflammation rather than direct pressure within the skull.

D. Lethargy:

This is the correct answer. Lethargy, or excessive drowsiness or fatigue, can be an early manifestation of increased intracranial pressure. As pressure increases within the skull, it can lead to alterations in consciousness ranging from lethargy to coma. Monitoring the client for changes in level of consciousness, including lethargy, is important for early detection of increased intracranial pressure.

A. B6 B. A C. E D. K E. C

Correct Answer is A

Explanation

A. B6 (Pyridoxine):

Vitamin B6, also known as pyridoxine, is known to reduce the therapeutic effects of levodopa. It competes with levodopa for absorption in the gastrointestinal tract and can decrease the amount of levodopa that reaches the brain, thereby diminishing its effectiveness in treating Parkinson's disease symptoms.

B. A (Retinol):

Vitamin A, also known as retinol, is not typically associated with reducing the therapeutic effects of levodopa. Vitamin A plays important roles in vision, immune function, and cellular communication, but it does not interact with levodopa in a way that affects its therapeutic efficacy.

C. E (Alpha-Tocopherol):

Vitamin E, also known as alpha-tocopherol, is an antioxidant that plays a role in protecting cells from oxidative damage. While vitamin E supplementation is sometimes used in Parkinson's disease management for its potential neuroprotective effects, it is not known to reduce the therapeutic effects of levodopa.

D. K (Phylloquinone):

Vitamin K, also known as phylloquinone, is primarily involved in blood clotting and bone metabolism. It does not interact with levodopa in a way that reduces its therapeutic effects.

E. C (Ascorbic Acid):

Vitamin C, also known as ascorbic acid, is not known to reduce the therapeutic effects of levodopa. While vitamin C has various roles in the body, including antioxidant activity and immune function support, it does not interfere with levodopa absorption or efficacy.

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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

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