A nurse is caring for a 76-year-old male client in an outpatient clinic.

Complete the diagram by dragging from the choices below to specify which potential condition the client is possibly experiencing, two actions the nurse should take when assessing the carotid arteries, and two parameters the nurse should continually monitor post initial findings.

Answer and Explanation

The Correct Answer is []

Condition: transient ischemic attack
2 actions: compress gently one carotid at a time, perform a full neurological exam
2 parameters: bruit, pulses

Rationale for correct condition
Transient ischemic attack (TIA) is caused by temporary cerebral ischemia, often due to carotid artery stenosis or embolism. The client’s mild disorientation and carotid bruit suggest impaired cerebral blood flow without permanent infarction. TIAs present as transient neurological symptoms resolving within 24 hours, consistent with intermittent confusion. This condition is a warning sign for potential future stroke and requires urgent evaluation. Early identification and intervention can prevent progression to stroke.

Rationale for correct actions
Compressing gently one carotid artery at a time helps assess pulse quality and detect possible vascular occlusion or stenosis while avoiding bilateral compression that can cause cerebral hypoperfusion. Performing a full neurological exam evaluates cognitive function, motor skills, and sensory deficits, identifying areas affected by transient ischemia and guiding further management. Both actions are essential to assess the extent of vascular and neurological involvement accurately.

Rationale for correct parameters
Monitoring the bruit helps track turbulent blood flow through a narrowed carotid artery, indicating worsening stenosis risk. Assessing pulses ensures adequate peripheral circulation and detects any changes from baseline that could signal embolic events. These parameters help evaluate the vascular status and risk of ischemic events continuously.

Rationale for incorrect conditions
Stroke results in permanent neurological deficits, not transient symptoms; the client is alert and only mildly disoriented. Aortic stenosis affects cardiac outflow, not carotid flow, and is unrelated to confusion or carotid bruits. Carotid artery dissection involves vessel wall injury causing acute symptoms like neck pain and ischemia, which the client lacks.

Rationale for incorrect actions
Having the patient lie down is unnecessary and may not improve cerebral perfusion. Administering supplemental oxygen is not indicated without hypoxia. Applying firm bilateral pressure can dangerously reduce cerebral blood flow causing syncope or stroke.

Rationale for incorrect parameters
Distended jugular veins indicate right heart failure, unrelated to carotid disease. Visual acuity changes are more associated with ophthalmic artery issues, not carotid bruits. Chest pain relates to cardiac ischemia, not carotid vascular assessment.

Take home points

transient ischemic attacks are brief episodes of cerebral ischemia without permanent damage
carotid bruits suggest arterial stenosis and increased stroke risk
neurological exams and careful vascular assessment are critical in TIA evaluation
differentiate TIA from stroke, cardiac causes, and carotid dissection for appropriate treatment

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Correct Answer is B

Explanation

Choice A rationale

Performing the tests regardless of mental status is incorrect because cognitive impairment, such as short-term memory loss and confusion, directly impacts a client's ability to comprehend and respond accurately to sensory testing. The validity of sensory assessment relies heavily on the client's cooperation and understanding of instructions.

Choice B rationale

Assessing the client's ability to follow directions before proceeding is crucial. Sensory examinations require the client to understand and comply with commands, such as identifying stimuli or performing specific movements. Cognitive decline can impair this ability, leading to unreliable test results if not addressed beforehand.

Choice C rationale

Deferring the exam entirely because results are likely invalid is not the best approach. While validity might be compromised, the nurse should first attempt to adapt the assessment. Modifications like simplified instructions, repeated commands, or utilizing familiar cues can often yield some useful information.

Choice D rationale

Explaining the tests to the wife for interpretation is insufficient and potentially misleading. While family input is valuable for history, sensory perception is subjective. The wife cannot accurately perceive or interpret the client's direct sensory experiences, which are essential for a valid assessment.

A. Share personal values to put the client at ease. B. Begin with Questions that are less sensitive in nature. C. Get the most difficult Questions over with first. D. Ask Questions in a vague, nonspecific format.

Correct Answer is B

Explanation

Choice A rationale

Sharing personal values can shift the focus from the client's needs to the nurse's experiences, potentially making the client uncomfortable or less willing to share. Professional boundaries dictate that the nurse maintains objectivity and prioritizes the client's therapeutic relationship and psychological safety. This approach can be perceived as unprofessional and may hinder trust.

Choice B rationale

Starting with less sensitive questions allows for rapport building and establishes a trusting environment. This gradual approach respects the client's potential hesitancy regarding a sensitive topic like family mental health history. It helps to decrease anxiety and resistance, making it more likely the client will eventually feel comfortable discussing more difficult subjects. This aligns with the principle of progressive disclosure in therapeutic communication.

Choice C rationale

Immediately addressing highly sensitive topics can overwhelm the client, leading to defensiveness, withdrawal, or an unwillingness to continue the discussion. This direct approach disregards the client's emotional state and the need for a therapeutic alliance, which is crucial for effective communication about delicate personal information. It may also lead to the client shutting down.

Choice D rationale

Vague or nonspecific questions can lead to misinterpretation and do not elicit accurate or comprehensive information. Precise, yet open-ended, questions are essential for effective data collection in a health history. Ambiguity can frustrate the client and prevent the nurse from obtaining the specific details necessary for a thorough assessment, hindering diagnostic accuracy.

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Naxlex Comprehensive Predictor Exams

While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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