The nurse completes percussion of the abdomen on an older adult client.
Which finding is considered normal for this client?

Choice A rationale:

"Tell me about your coping strategies and support system." This is an appropriate statement during the assessment of a client with panic disorder. Understanding the client's coping mechanisms and support system can help the nurse tailor the care plan to the client's specific needs and strengths.

Choice B rationale:

"How often do you experience panic attacks and what triggers them?" While this question may be relevant, it focuses primarily on the frequency and triggers of panic attacks. While this information is important, it doesn't address coping strategies or support systems, which are equally important aspects of the assessment.

Choice C rationale:

"What medications are you currently taking for your panic disorder?" This question is essential for medication management but does not directly address coping strategies or support systems, which are more pertinent to the assessment in this context.

Choice D rationale:

"Have you ever had any laboratory tests done for your panic disorder?" This question is not relevant to the assessment of panic disorder. Panic disorder is primarily diagnosed based on clinical criteria and does not require specific laboratory tests.

Choice A rationale:

Beginning continuous observation for transient episodes of neurologic dysfunction is important in the assessment and monitoring of the client's condition. However, in this scenario, the client is presenting with symptoms suggestive of a possible stroke or cerebrovascular event, and time is crucial. The nurse should prioritize actions that can lead to prompt diagnosis and treatment.

Choice B rationale:

Starting two large bore intravenous (IV) catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the most urgent action. The client's symptoms, including sudden right-sided numbness, weakness, and facial droop, are indicative of a possible ischemic stroke. IV fibrinolytic therapy is time-sensitive and has a limited window of effectiveness. Establishing IV access and determining eligibility for this therapy should be the nurse's top priority to potentially improve the client's outcome.

Choice C rationale:

Administering aspirin to prevent further clot formation and platelet clumping is an important intervention in the treatment of ischemic stroke. However, it should not be the first action in this scenario. The priority is to assess for eligibility for IV fibrinolytic therapy, as this intervention has a more immediate impact on reversing the stroke's effects.

Choice D rationale:

Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is a reasonable nursing intervention to prevent complications such as aspiration and promote optimal cerebral blood flow. However, it is not the most urgent action in this case. The priority should be on assessing and potentially treating the stroke with IV fibrinolytic therapy.