Exhibits

Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition: Transient ischemic stroke (d)

2 actions:

Request a prescription for a computerized tomography (CT) scan of the client's head and neck (d)
Perform a National Institute of Health Stroke Scale (NIHSS) assessment (e)

2 parameters:

Neurological status (a)
Blood pressure (c)

Rationale for correct condition: A transient ischemic stroke (TIA) is a temporary period of symptoms similar to those of a stroke and is often a precursor to a full-blown stroke. The patient's symptoms of dizziness, weakness, and a horrible headache, combined with his history of hypertension and atrial fibrillation, suggest a high risk for a TIA. The patient's confusion about the date and time also supports this condition. Immediate assessment and intervention are crucial to prevent a possible stroke.

Rationale for the two correct actions:

Request a prescription for a CT scan: This is essential to identify any blockages or abnormalities in the blood vessels of the brain, confirming the presence and extent of a TIA or stroke.
Perform an NIHSS assessment: This standardized tool is used to evaluate the severity of a stroke and to monitor changes in the patient's neurological status over time.

Rationale for parameters to monitor:

Neurological status: Monitoring this parameter helps track changes in the patient's cognitive and motor functions, which are critical in assessing the progression or improvement of the stroke symptoms.
Blood pressure: Hypertension is a major risk factor for strokes. Keeping a close watch on the blood pressure helps in managing and reducing the risk of further complications.

Rationale for incorrect conditions:

Hypoglycemia: While it can cause dizziness and weakness, the patient's recent UTI and headache are not typical for hypoglycemia.
Hemorrhagic stroke: This would typically present with more severe neurological symptoms and possible loss of consciousness.
Urinary tract infection: The patient's symptoms go beyond those of a UTI, especially given the headache, dizziness, and confusion.

Rationale for incorrect actions to take:

Administer 0.9% sodium chloride IV: Not specific to stroke management and doesn't address the immediate risk.
Administer oxygen via nasal cannula: The patient's oxygen saturation is normal; thus, this is not immediately necessary.
Request a prescription for the client's home medication of aspirin: While aspirin is used for stroke prevention, administering it without confirming the stroke type (ischemic vs hemorrhagic) could be harmful.

Rationale for incorrect parameters to monitor:

Respiratory rate: This is not directly related to stroke assessment.
Urine output: Irrelevant to the immediate management of TIA.
Oxygen saturation: The patient's oxygen levels are normal, so monitoring it won't provide further insights.

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Correct Answer is C

Explanation

Choice A reason: Ensuring the IV solution is infusing at the prescribed rate is important, but it is not the first action the nurse should take. The symptoms the client is exhibiting—low blood pressure, tachycardia, restlessness, and irritability—are indicative of potential hypovolemic shock, likely due to bleeding. Immediate assessment for bleeding is more critical.

Choice B reason: Notifying the healthcare provider of the findings is essential, but it should be done after assessing the client for signs of bleeding. The nurse needs to quickly identify the source of the client’s symptoms before contacting the healthcare provider to provide a complete and accurate report of the situation.

Choice C reason: Checking under the back for evidence of bleeding is the correct first action. The client's symptoms suggest they might be experiencing hypovolemic shock due to postoperative bleeding. Identifying whether there is visible bleeding can help determine the next steps in managing the client's condition and providing appropriate interventions.

Choice D reason: Listening to lung sounds is important in a comprehensive assessment but is not the priority in this scenario. The client's symptoms strongly indicate a potential bleeding issue, so checking for evidence of bleeding should come first to promptly address the most life-threatening concern.

A. Administer a PRN dose of an antispasmodic agent B. Increase the flow of the bladder irrigation C. Measure the client's intake and output D. Provide additional oral fluid intake

Correct Answer is B

Explanation

Choice A reason: Administering a PRN dose of an antispasmodic agent can help relieve bladder spasms that often occur after TURP, but it does not address the immediate issue of blood clots blocking the drainage tubing. The primary concern is to ensure the patency of the catheter and proper drainage.

Choice B reason: Increasing the flow of the bladder irrigation is the best initial action. By increasing the flow, the nurse can help flush out the blood clots from the drainage tubing and ensure that the catheter remains patent. This action directly addresses the problem of blocked drainage and prevents further complications.

Choice C reason: Measuring the client's intake and output is important for overall monitoring, but it does not directly address the immediate concern of blood clots in the drainage tubing. Ensuring proper drainage is crucial to prevent complications such as bladder distention and further bleeding.

Choice D reason: Providing additional oral fluid intake is beneficial for maintaining hydration and promoting urine output, but it does not solve the problem of blood clots in the drainage tubing. The primary focus should be on ensuring the catheter's patency through irrigation.

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Exhibits Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

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Explanation

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Explanation

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Exhibits Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

Exhibits

Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.