A triage nurse is assessing a client who has a history of hypertension. Which of the following findings should the nurse identify as an indication that the client is having a transient ischemic attack? (Select all that apply.)
Dry mouth
Aphasia
Vertigo
Diplopia
Hearing loss
Correct Answer : B,C,D
A. Dry mouth is not typically associated with transient ischemic attacks (TIAs).
B. Aphasia (difficulty speaking or understanding speech) is a common neurological symptom of a TIA.
C. Vertigo (a sensation of spinning) can occur during a TIA affecting the brainstem or cerebellum.
D. Diplopia (double vision) is a neurological symptom that can occur with TIAs.
E. Hearing loss is not a typical symptom of TIA.
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Related Questions
Correct Answer is D
Explanation
A. Medication reconciliation involves more than just comparing prescriptions; it requires reviewing all current medications, including over-the-counter drugs and supplements, for potential issues.
B. The nurse should not delete any prescriptions; instead, notify the provider of any concerns or potential interactions.
C. Medication reconciliation should be performed at every transition of care (admission, transfer, and discharge), not just admission and discharge.
D. Considering the risk for medication interactions is a key step in medication reconciliation. The nurse must evaluate potential interactions between home medications and new prescriptions to ensure safe and effective care.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Administer an iron supplement: Client has iron-deficiency anemia evidenced by low hemoglobin, hematocrit, and ferritin. Iron supplementation is first-line therapy, especially for clients with vegan diets who lack dietary iron.
Restrict fluid intake: This is contraindicated for this client. There is no evidence of fluid overload, CHF, or renal failure requiring restriction. Fluid restriction could worsen fatigue, hypotension, and perfusion.
Place the client on a low sodium diet: This is not critical for current anemia management. May be beneficial for long-term hypertension management, but not directly related to anemia treatment.
Refer for a nutritional consult: Client follows a vegan diet and is at risk for iron and B12 deficiency. A dietitian can provide guidance on iron-rich plant foods, B12 supplementation, and balanced nutrition.
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