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.

Answer and Explanation

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.

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Correct Answer is ["0.3"]

Explanation

Step 1: Convert the client's weight from lbs to kg using the conversion factor you provided (1 kg = 2.2 lbs).

So, 110 lbs × (1 kg ÷ 2.2 lbs) = 50 kg

Step 2: Calculate the daily dosage of dalteparin in units using the prescription (150 units/kg).

So, 50 kg × 150 units/kg = 7500 units

Step 3: Determine how many mL of the medication this dosage corresponds to using the information on the syringe (7500 units/0.3 mL).

So, 7500 units × (0.3 mL ÷ 7500 units) = 0.3 mL

The nurse should administer 0.3 mL of dalteparin to the client.

A. "What did the night nurse do that makes you think the nurse is aloof?" B. "Tomorrow I will talk to that nurse about how you were treated last night." C. "I am happy that you are getting better and will be able to go home." D. "I am glad you like me. Which nurse was acting aloof to you?"

Correct Answer is C

Explanation

Choice A reason: Asking for specifics about the night nurse's behavior could reinforce the client's splitting behavior, which is not therapeutic.

Choice B reason: Promising to talk to the night nurse may validate the client's negative perception without understanding the full context.

Choice C reason: Focusing on the client's progress and upcoming discharge avoids engaging in a discussion that could reinforce dichotomous thinking.This response is non-confrontational and avoids engaging in the client’s dichotomous thinking. It focuses on the positive aspect of the client’s situation, which is their improvement and discharge from the hospital. It’s important for healthcare professionals to maintain professional boundaries and not reinforce potentially harmful behavior patterns.

Choice D reason: Seeking details about the client's preference for certain staff can encourage splitting behavior and is not beneficial.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who weighs 110 lbs has received a prescription for dalteparin, 150 units/kg to be administered subcutaneously daily for 4 months. The medication is available in a 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Please enter the numerical value only.)

Correct Answer is ["0.3"]

Explanation

Correct Answer is C

Explanation

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