A nurse is caring for a client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?

Epigastric pain

Seizure activity

Sudden loss of vision in one eye

Pain radiating down the left arm

Answer and Explanation

The Correct Answer is C

Choice A reason: Epigastric pain suggests GI issues, not TIAs. In hypertension, TIAs affect cerebral vessels, causing neurological deficits, not abdominal symptoms like this.

Choice B reason: Seizures stem from cortical irritation, not typical TIA vascular occlusion. Hypertension-related TIAs produce transient deficits, not convulsive activity usually.

Choice C reason: Sudden monocular vision loss (amaurosis fugax) is a classic TIA sign in hypertension. It reflects temporary retinal artery occlusion, resolving quickly.

Choice D reason: Left arm pain mimics cardiac issues, not TIAs. Hypertension TIAs target brain circulation, causing focal deficits, not referred pain patterns.

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Correct Answer is C

Explanation

Choice A reason: A chaplain offers spiritual support, but it’s not the nurse’s primary role. Autonomy in end-stage kidney disease takes precedence over initiating such visits.

Choice B reason: Alternatives don’t apply post-decision in end-stage disease; dialysis cessation reflects prognosis acceptance. Discussing them now dismisses the client’s informed choice.

Choice C reason: Supporting the decision respects autonomy in end-stage kidney disease. It aligns with palliative care, honoring the client’s right to refuse treatment.

Choice D reason: Suggesting family discussion undermines autonomy, adding pressure. In terminal illness, the client’s choice to stop dialysis should be respected directly.

A. Diminished pulses on the affected extremity B. Ecchymosis on the inner left thigh C. Client report of muscle spasms of the left leg D. One fingerbreadth of space between the cast and the skin

Correct Answer is A

Explanation

Choice A reason: Diminished pulses signal compromised circulation, a critical cast complication like compartment syndrome. This risks tissue necrosis or amputation if untreated, prioritizing it scientifically, as arterial flow disruption demands immediate intervention to preserve limb viability per vascular assessment standards.

Choice B reason: Ecchymosis suggests bruising, possibly from cast pressure, but isn’t immediately life-threatening like poor circulation. It’s a secondary concern, manageable later. Scientifically, it indicates trauma, not acute vascular emergency, ranking lower in urgency per cast complication protocols.

Choice C reason: Muscle spasms may indicate irritation or pressure, but they’re less urgent than absent pulses. Pain is common in casts, not always critical. Scientifically, this suggests nerve or muscle stress, not imminent tissue loss, making it a lower priority for immediate action.

Choice D reason: One fingerbreadth space is normal, preventing tightness, not a concern. It’s ideal fit, not a problem. Scientifically, this aligns with safe cast application, lacking urgency compared to circulatory threats, as it supports, rather than jeopardizes, limb health.

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A nurse is caring for a client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

Correct Answer is A

Explanation

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