Exhibits
Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition: Transient ischemic stroke (d)
2 actions:
- Request a prescription for a computerized tomography (CT) scan of the client's head and neck (d)
- Perform a National Institute of Health Stroke Scale (NIHSS) assessment (e)
2 parameters:
- Neurological status (a)
- Blood pressure (c)
Rationale for correct condition: A transient ischemic stroke (TIA) is a temporary period of symptoms similar to those of a stroke and is often a precursor to a full-blown stroke. The patient's symptoms of dizziness, weakness, and a horrible headache, combined with his history of hypertension and atrial fibrillation, suggest a high risk for a TIA. The patient's confusion about the date and time also supports this condition. Immediate assessment and intervention are crucial to prevent a possible stroke.
Rationale for the two correct actions:
- Request a prescription for a CT scan: This is essential to identify any blockages or abnormalities in the blood vessels of the brain, confirming the presence and extent of a TIA or stroke.
- Perform an NIHSS assessment: This standardized tool is used to evaluate the severity of a stroke and to monitor changes in the patient's neurological status over time.
Rationale for parameters to monitor:
- Neurological status: Monitoring this parameter helps track changes in the patient's cognitive and motor functions, which are critical in assessing the progression or improvement of the stroke symptoms.
- Blood pressure: Hypertension is a major risk factor for strokes. Keeping a close watch on the blood pressure helps in managing and reducing the risk of further complications.
Rationale for incorrect conditions:
- Hypoglycemia: While it can cause dizziness and weakness, the patient's recent UTI and headache are not typical for hypoglycemia.
- Hemorrhagic stroke: This would typically present with more severe neurological symptoms and possible loss of consciousness.
- Urinary tract infection: The patient's symptoms go beyond those of a UTI, especially given the headache, dizziness, and confusion.
Rationale for incorrect actions to take:
- Administer 0.9% sodium chloride IV: Not specific to stroke management and doesn't address the immediate risk.
- Administer oxygen via nasal cannula: The patient's oxygen saturation is normal; thus, this is not immediately necessary.
- Request a prescription for the client's home medication of aspirin: While aspirin is used for stroke prevention, administering it without confirming the stroke type (ischemic vs hemorrhagic) could be harmful.
Rationale for incorrect parameters to monitor:
- Respiratory rate: This is not directly related to stroke assessment.
- Urine output: Irrelevant to the immediate management of TIA.
- Oxygen saturation: The patient's oxygen levels are normal, so monitoring it won't provide further insights.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Eliminating whole milk and dairy servings of ice cream is an appropriate choice for a client with cholecystitis. These foods are high in fat, and a low-fat diet is recommended for managing cholecystitis. High-fat foods can stimulate the gallbladder to contract, which can exacerbate symptoms and cause pain. By removing these high-fat items from their diet, the client is following the recommended dietary guidelines for managing cholecystitis.
Choice B reason: Eliminating citrus fruit and melon with a salt substitute does not specifically address the dietary recommendations for cholecystitis. While citrus fruits and melon are generally healthy choices, they are not high in fat and do not need to be eliminated from the diet. Additionally, using a salt substitute does not have a significant impact on cholecystitis management.
Choice C reason: Eliminating pasta with herbal butter and no meat sauce is not necessary for managing cholecystitis. Pasta itself is not high in fat, and using herbal butter instead of regular butter can be a lower-fat option. As long as the pasta dish is prepared with low-fat ingredients, it can be part of a cholecystitis-friendly diet.
Choice D reason: Eliminating canned vegetables with additional table salt does not specifically address the dietary recommendations for cholecystitis. While it is generally a good idea to limit sodium intake for overall health, this recommendation is more relevant for managing conditions like hypertension. The focus for cholecystitis management should be on reducing dietary fat rather than sodium.
Correct Answer is C
Explanation
Choice A reason: Administering PRN pain medication can help manage the client's discomfort, but it does not address the underlying cause of the pain. It is essential to assess and identify the source of the pain before administering pain relief. Providing pain medication without a thorough assessment may mask symptoms of a serious underlying issue.
Choice B reason: Observing the leg for swelling is important, as swelling can indicate complications such as compartment syndrome or infection. However, it is not the first action the nurse should take. While swelling is a significant sign, assessing blood flow to the extremity is more critical and should be prioritized.
Choice C reason: Assessing peripheral pulses is the correct first intervention. The presence of foot pain in a client with an external fixation device for a fractured femur could indicate compromised blood flow to the lower extremity. Assessing the peripheral pulses will help determine if there is adequate circulation. If pulses are weak or absent, it may suggest a serious vascular issue that requires immediate intervention to prevent further complications such as tissue ischemia or necrosis.
Choice D reason: Auscultating blood pressure is a routine assessment but does not directly address the immediate concern of left foot pain in this scenario. Blood pressure assessment is important for overall health monitoring but is not the priority when dealing with a possible vascular complication in the affected limb. Ensuring adequate blood flow to the extremity takes precedence.
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