When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care?
Assess bilateral breath sounds.
Palpate the suprapubic region for urinary retention.
Review the client's daily medications.
Initiate neurological monitoring every 2 hours.
The Correct Answer is D
Choice A reason: While assessing breath sounds is part of a comprehensive evaluation, it is not the most critical intervention for a TIA, which primarily affects neurological function.
Choice B reason: Palpating the suprapubic region for urinary retention is important but not the priority intervention for a client with TIA, as it does not directly relate to the risk of stroke.
Choice C reason: Reviewing the client's daily medications is necessary for overall care but is not the most immediate concern upon admission for a TIA.
Choice D reason: Initiating neurological monitoring every 2 hours is essential for a client with TIA to promptly identify any changes or progression in neurological status, which could indicate a stroke. This is the most important intervention to include in the plan of care for a client admitted with TIA. Neurological monitoring allows for immediate intervention if the client's condition worsens, potentially preventing further ischemic damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A blood pressure of 130/80 mm Hg is considered high normal and may not require immediate follow-up for a patient with a history of hypertension.
Choice B reason: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.
Choice C reason: Dark yellow urine could be a sign of dehydration, which is common in diabetes, but it is not as concerning as an elevated serum creatinine level.
Choice D reason: Difficulty staying asleep could be related to various factors and may require follow-up, but it is not as urgent as abnormal laboratory values.
Correct Answer is ["A","E"]
Explanation
Choice A reason: Allergic rhinitis is a common condition that responds well to antihistamines, which can alleviate symptoms such as sneezing, runny nose, and itching.
Choice B reason: Otitis media is an inflammation of the middle ear and is not typically treated with antihistamines.
Choice C reason: Myocarditis is an inflammation of the heart muscle and is not treated with antihistamines.
Choice D reason: Bronchitis involves inflammation of the bronchial tubes and is not primarily treated with antihistamines.
Choice E reason: Contact dermatitis, which is an allergic skin reaction, can be treated with antihistamines to relieve itching and rash.
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