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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.

Answer and Explanation

The Correct Answer is []

Condition: Transient ischemic stroke (d)

2 actions:

  1. Request a prescription for a computerized tomography (CT) scan of the client's head and neck (d)
  2. Perform a National Institute of Health Stroke Scale (NIHSS) assessment (e)

2 parameters:

  1. Neurological status (a)
  2. 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:

  1. 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.
  2. 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:

  1. 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.
  2. 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:

  1. Hypoglycemia: While it can cause dizziness and weakness, the patient's recent UTI and headache are not typical for hypoglycemia.
  2. Hemorrhagic stroke: This would typically present with more severe neurological symptoms and possible loss of consciousness.
  3. 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:

  1. Administer 0.9% sodium chloride IV: Not specific to stroke management and doesn't address the immediate risk.
  2. Administer oxygen via nasal cannula: The patient's oxygen saturation is normal; thus, this is not immediately necessary.
  3. 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:

  1. Respiratory rate: This is not directly related to stroke assessment.
  2. Urine output: Irrelevant to the immediate management of TIA.
  3. Oxygen saturation: The patient's oxygen levels are normal, so monitoring it won't provide further insights.


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Related Questions

Correct Answer is C

Explanation

Choice A reason: Encouraging the client to lie down and rest after meals is not advisable for someone with gastroesophageal reflux. Lying down after eating can exacerbate symptoms by allowing stomach acid to more easily flow back into the esophagus. It's recommended that clients stay upright for at least 2-3 hours after meals.

Choice B reason: Avoiding high-fiber foods is not a standard recommendation for managing gastroesophageal reflux. In fact, a diet high in fiber can benefit overall digestive health and help prevent constipation. The key dietary advice usually involves avoiding trigger foods such as spicy, fatty, or acidic foods.

Choice C reason: Elevating the head of the bed on blocks is an effective way to manage gastroesophageal reflux, especially at night. This position helps keep stomach acid in the stomach and prevents it from flowing back into the esophagus, reducing symptoms such as heartburn.

Choice D reason: Instructing the client to use antacids only as a last resort is not necessarily accurate advice. While antacids can provide symptomatic relief, they are often used as part of a comprehensive management plan for gastroesophageal reflux. However, lifestyle modifications and dietary changes are also crucial.

Correct Answer is C

Explanation

Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access.

Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction.

Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation.

Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction.

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