A client who has experienced an initial transient ischemic attack (TIA) states: “I’m glad it wasn’t anything serious.” Which is the best nursing response to this statement?

I sense that you are happy it was not a stroke

TIA symptoms are short-lived and resolve within 24 hours

People who experience a TIA will develop a stroke

TIA is a warning sign. Let’s talk about lowering your risks

Answer and Explanation

The Correct Answer is D

Reasoning:

Choice A reason: Acknowledging the client’s relief does not educate them about the TIA’s significance. TIAs indicate transient cerebral ischemia, increasing stroke risk, but this response fails to address the need for risk modification, missing an opportunity to promote preventive measures critical for stroke prevention.

Choice B reason: Stating that TIA symptoms resolve within 24 hours is factually correct but does not emphasize the serious nature of TIAs as stroke precursors. Without addressing risk reduction, this response fails to educate the client on the need for lifestyle changes or medical intervention to prevent future events.

Choice C reason: Saying all TIA patients will develop a stroke is inaccurate, as not all progress to stroke. TIAs significantly increase stroke risk, but many can be prevented with proper management. This response is overly fatalistic and does not encourage proactive risk reduction strategies.

Choice D reason: Explaining that a TIA is a warning sign and discussing risk reduction educates the client about its significance as a transient cerebral ischemia event, increasing stroke risk. This response promotes lifestyle changes, medication adherence, and medical follow-up, empowering the client to prevent future strokes effectively.

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Correct Answer is ["A","C","D"]

Explanation

Reasoning:

Choice A reason: Dry mucous membranes support diabetes insipidus, as excessive water loss from polyuria due to ADH deficiency causes dehydration. This reduces moisture in mucosal tissues, leading to dryness in the mouth and throat, a common physical finding in dehydrated states associated with uncontrolled diabetes insipidus.

Choice B reason: Weight gain is not consistent with diabetes insipidus, which causes water loss through polyuria, leading to dehydration and potential weight loss. Weight gain is more typical of conditions like SIADH, where water retention increases body fluid volume, diluting sodium and causing hyponatremia.

Choice C reason: Poor skin turgor is a sign of dehydration, supporting diabetes insipidus. ADH deficiency leads to excessive dilute urine output, reducing body water content. This causes skin to lose elasticity, as subcutaneous tissues become dehydrated, making poor skin turgor a key physical finding in this condition.

Choice D reason: Hypotension is a clinical sign of diabetes insipidus due to hypovolemia from excessive water loss. Reduced blood volume decreases blood pressure, as the cardiovascular system struggles to maintain perfusion. This finding supports the nurse’s suspicion, as dehydration from polyuria is a hallmark of the condition.

Choice E reason: Decreased heart rate, or bradycardia, is not typical in diabetes insipidus. Dehydration from polyuria typically causes tachycardia as the heart compensates for reduced blood volume. A decreased heart rate may indicate another condition but does not support the diagnosis of diabetes insipidus in this context.

A. Offer liquids frequently, in large quantities B. Allow optimum physical activity before meals to expedite digestion C. Help the client sit upright when eating and feed slowly D. Instruct the client to lie on the bed when eating

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Offering large quantities of liquids frequently increases aspiration risk in clients with dysphagia from neurological disorders. Large volumes can overwhelm swallowing mechanisms, leading to choking or pneumonia. Controlled, small sips with proper positioning are safer to ensure nutrition without compromising airway safety.

Choice B reason: Allowing physical activity before meals may improve appetite but does not address swallowing difficulties. Activity does not facilitate safe swallowing in neurological disorders, where muscle coordination is impaired. Proper positioning and pacing during feeding are more effective to prevent aspiration and ensure nutritional intake.

Choice C reason: Helping the client sit upright and feeding slowly minimizes aspiration risk in neurological dysphagia. Upright positioning aligns the airway to prevent food or liquid entry, and slow feeding allows better coordination of swallowing muscles, reducing choking and ensuring adequate nutrition, critical for safe intake.

Choice D reason: Instructing the client to lie down while eating is dangerous in dysphagia, as it increases aspiration risk. Lying down allows food or liquids to enter the airway, potentially causing pneumonia. Upright positioning is essential to facilitate safe swallowing and prevent complications in neurological disorders.

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A client who has experienced an initial transient ischemic attack (TIA) states: “I’m glad it wasn’t anything serious.” Which is the best nursing response to this statement?

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Correct Answer is ["A","C","D"]

Explanation

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client’s diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client’s diet allows for easy swallowing?

Correct Answer is C

Explanation

A client who is in the third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the client’s iron stores?

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Which is a clinical manifestation of diabetes insipidus?