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

Explanation

Reasoning:

Choice A reason: Early mobilization post-ischemic stroke is critical during recovery to prevent complications like deep vein thrombosis, pneumonia, and muscle atrophy. It promotes neuroplasticity, improves circulation, and enhances functional recovery, making it a priority intervention in the immediate recovery period to optimize outcomes and reduce disability.

Choice B reason: Maximizing PaCO2 is not appropriate post-ischemic stroke. Elevated CO2 causes cerebral vasodilation, potentially increasing ICP, which is harmful. Maintaining normal CO2 levels supports cerebral perfusion without exacerbating edema, making this intervention irrelevant or potentially dangerous in stroke recovery.

Choice C reason: Positioning to avoid ICP is more relevant for hemorrhagic stroke, where ICP is a concern. In ischemic stroke, ICP is less likely unless severe edema occurs. Early mobilization takes precedence to prevent complications and promote recovery, making ICP positioning a secondary concern.

Choice D reason: Administering hypertonic IV solutions is used in cases of cerebral edema or elevated ICP, more common in hemorrhagic stroke. In ischemic stroke, hydration with isotonic fluids supports perfusion, but early mobilization is the priority to enhance recovery and prevent immobility-related complications.

A. Thiazide diuretics B. Diabinese C. Desmopressin (DDAVP) D. Ibuprofen

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Thiazide diuretics reduce urine output in nephrogenic diabetes insipidus by increasing sodium excretion, which enhances water reabsorption indirectly. However, they are not the primary treatment for central diabetes insipidus, where ADH deficiency is the issue. Desmopressin, an ADH analog, directly addresses the hormonal deficiency, making thiazides less effective.

Choice B reason: Diabinese (chlorpropamide) is a sulfonylurea used for type 2 diabetes mellitus, not diabetes insipidus. It lowers blood glucose by stimulating insulin release, which is irrelevant to the water balance issue in diabetes insipidus caused by ADH deficiency. It does not address the underlying hormonal imbalance.

Choice C reason: Desmopressin (DDAVP) is a synthetic ADH analog used to treat central diabetes insipidus. It mimics ADH, promoting water reabsorption in the kidneys’ collecting ducts, reducing polyuria and thirst. This directly corrects the fluid imbalance caused by ADH deficiency, making it the primary and most effective treatment.

Choice D reason: Ibuprofen, a nonsteroidal anti-inflammatory drug, is used for pain and inflammation, not for fluid balance in diabetes insipidus. It has no effect on ADH or renal water reabsorption, making it irrelevant for treating the excessive urine output and dehydration associated with this condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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