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 ["A","B","D","F"]
Explanation
Choice A Reason: Weight reduction treatment is a modifiable risk factor for prediabetes. Losing a small amount of weight, around 5% to 7% of body weight, can significantly lower the risk of developing type 2 diabetes. For a 200-pound person, this means losing about 10 to 14 pounds.
Choice B Reason: Exercise planning is crucial as it helps improve insulin sensitivity and glucose metabolism. The recommendation is at least 150 minutes per week of moderate-intensity physical activity, such as brisk walking or light cycling.
Choice C Reason: Long-acting insulin is not typically used in the management of prediabetes. Insulin therapy is more commonly a part of the treatment regimen for individuals with type 1 diabetes or those with type 2 diabetes who cannot control their blood glucose levels with oral medications.
Choice D Reason: Nutrition education is essential for managing prediabetes. A diet rich in fiber, whole grains, and non-starchy vegetables, and low in added sugars and saturated fats, can help manage blood glucose levels3.
Choice E Reason: Extra carbohydrates are not recommended for prediabetes management as they can lead to increased blood glucose levels. Instead, a balanced diet with controlled carbohydrate intake is advised.
Choice F Reason: Oral antidiabetic medications, such as metformin, may be prescribed to help lower blood glucose levels and improve insulin sensitivity in individuals with prediabetes.
Choice G Reason: Short-acting insulin is not indicated for prediabetes management for the same reasons as long-acting insulin; it is not typically part of the treatment regimen unless the individual has progressed to type 2 diabetes and requires insulin therapy.
Correct Answer is B
Explanation
Choice A reason: While living in older housing projects can pose a risk, the age of the child and their behaviors, such as hand-to-mouth activities, make younger children more susceptible.
Choice B reason: A 2-year-old is at the highest risk due to their developmental stage, which includes frequent hand-to-mouth activity and the likelihood of playing in soil or dust that may be contaminated with lead.
Choice C reason: Adolescents working in a paint factory may be exposed to lead; however, they are less likely to engage in hand-to-mouth behaviors that lead to ingestion, which is the primary route of lead poisoning in children.
Choice D reason: A 10-year-old with Type 1 diabetes mellitus does not have an increased risk of lead poisoning based on their condition alone.
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