When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care?

Assess bilateral breath sounds.

Palpate the suprapubic region for urinary retention.

Review the client's daily medications.

Initiate neurological monitoring every 2 hours.

Answer and Explanation

The Correct Answer is D

Choice A reason: While assessing breath sounds is part of a comprehensive evaluation, it is not the most critical intervention for a TIA, which primarily affects neurological function.

Choice B reason: Palpating the suprapubic region for urinary retention is important but not the priority intervention for a client with TIA, as it does not directly relate to the risk of stroke.

Choice C reason: Reviewing the client's daily medications is necessary for overall care but is not the most immediate concern upon admission for a TIA.

Choice D reason: Initiating neurological monitoring every 2 hours is essential for a client with TIA to promptly identify any changes or progression in neurological status, which could indicate a stroke. This is the most important intervention to include in the plan of care for a client admitted with TIA. Neurological monitoring allows for immediate intervention if the client's condition worsens, potentially preventing further ischemic damage.

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Correct Answer is D

Explanation

Choice A reason: Sudden swelling, redness, warmth, and pain are more indicative of acute conditions like deep vein thrombosis rather than chronic arterial symptoms.

Choice B reason: Weeping ulcers on lower legs are more commonly associated with venous insufficiency rather than arterial disease.

Choice C reason: Ankle edema and varicose veins are typically associated with venous disorders, not arterial disease.

Choice D reason: Intermittent claudication, which is pain during walking that subsides with rest, is a hallmark of peripheral arterial disease and is an expected finding in clients with this condition.

A. Delirium is often a sign of underlying mental illness, and institutionalization is often necessary. B. If the dementia is a result of Alzheimer's disease, it is often reversible even in the late stages. C. The client's delirium may be due to depression and is possibly reversible. D. The client is exhibiting symptoms of dementia, and because of age, it may be permanent.

Correct Answer is C

Explanation

Choice A reason: Suggesting that delirium is often a sign of underlying mental illness and that institutionalization is necessary can be distressing and may not be accurate without further assessment.

Choice B reason: Stating that dementia due to Alzheimer's disease is often reversible even in the late stages is incorrect; Alzheimer's disease is a progressive condition with no current cure.

Choice C reason: Recognizing the possibility of delirium due to depression, which can be reversible, is a hopeful and constructive approach that encourages further evaluation and treatment options.

Choice D reason: Suggesting that symptoms of dementia are permanent because of age can be disheartening and does not consider the potential for reversible causes of cognitive impairment.

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When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care?

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Explanation

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