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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Choice A Reason: Decreasing portion sizes can help manage calorie intake and contribute to weight loss, which is beneficial for individuals with prediabetes or diabetes. Proper portion control is also essential for maintaining blood sugar levels within the target range.
Choice B Reason: Avoiding potassium-rich foods is not a standard dietary recommendation for diabetes management unless the individual has a specific condition like kidney disease that requires potassium restriction.
Choice C Reason: Eating only plant-based foods is not necessary for diabetes management. While a plant-based diet can be part of a healthy eating plan, it is not required for all individuals with diabetes.
Choice D Reason: Choosing a well-rounded diet ensures that all necessary nutrients are included, which is important for overall health and can help manage blood sugar levels. A balanced diet for diabetes should include a variety of foods from all food groups.
Choice E Reason: Eliminating carbohydrates is not recommended for diabetes management. Carbohydrates are a necessary part of a healthy diet, and individuals with diabetes should focus on the type and amount of carbohydrates consumed rather than eliminating them entirely.
Choice F Reason: Replacing refined sugar with honey or molasses is not necessarily beneficial for diabetes management. While these are natural sweeteners, they still affect blood sugar levels and should be used in moderation.
Correct Answer is A
Explanation
Choice A: Advise the UAP to resume positioning the client on schedule.
Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.
Choice B: Encourage the UAP to provide comfort care measures only.
Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.
Choice C: Assume total care of the client to monitor neurologic function.
Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.
Choice D: Assign a practical nurse to assist the UAP in turning the client.
Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.
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