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 C
Explanation
Choice A reason: While obtaining a urine specimen is important for diagnosing infection, it does not address the immediate discomfort and potential urinary retention the client may be experiencing.
Choice B reason: Cleansing the glans penis is part of good hygiene but does not address the client's symptoms of a full bladder and weak urine flow.
Choice C reason: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.
Choice D reason: Maintaining a voiding diary is useful for tracking symptoms over time but does not provide an immediate assessment or intervention for the client's current symptoms.
Correct Answer is C
Explanation
Choice A reason: Removing dentures or other oral appliances may be necessary for some medical procedures, but it is not the most important intervention for a client with OSA who has just received an opioid patch.
Choice B reason: Lifting and locking the side rails in place is a standard safety measure, but it does not directly address the respiratory concerns associated with OSA and opioid use.
Choice C reason: Applying the client's positive airway pressure device is the most important intervention. Opioids can depress respiration, and for a client with OSA, ensuring the airway is patent and supported by a positive airway pressure device is crucial to prevent respiratory complications.
Choice D reason: Elevating the head of the bed can aid in respiration, but it is not as immediately critical as ensuring the use of a positive airway pressure device for a client with OSA who is receiving opioids.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
