Nokea
A client who has experienced an initial transient ischemic attack (TIA) states: 'I'm glad it wasn't anything serious.' Which is the best nursing response to this statement?
- A. I sense that you are happy it was not a stroke.
- B. People who experience a TIA will develop a stroke.
- C. TIA symptoms are short-lived and resolve within 24 hours.
- D. TIA is a warning sign. Let's talk about lowering your risks.
Correct Answer: D
Rationale: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.
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The nurse is providing teaching to a client who reports tension headaches. Which instruction would be beneficial to prevent onset of symptoms?
- A. Apply cool or warm cloth to head or eyes.
- B. Eliminate use of bright lights when working.
- C. Avoid certain foods.
- D. Perform stretching exercises and frequent position changes.
Correct Answer: D
Rationale: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches but is not likely to prevent tension headaches.
A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
- A. Avoid heavy lifting.
- B. Avoid fiber in the diet.
- C. Take an antacid frequently.
- D. Take an herbal form of feverfew.
Correct Answer: A
Rationale: A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead to constipation and straining with stools and would not be recommended. There would not be a recommendation for antacids or feverfew in the discharge teaching.
An older adult client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?
- A. Becoming confused during the night
- B. Drooling from side of mouth
- C. Bruit heard over carotids
- D. Irregular heart rhythm
Correct Answer: B
Rationale: Facial droop and drooling from the side of the mouth can indicate progression of symptoms or evolving CVA. It is not unusual for older adult clients to become confused when placed in a new environment and would indicate a need for further assessment. Bruits over the carotids may indicate altered blood flow to the brain but may not be a new finding for this client. Irregular heart rate can be indicative of atrial fibrillation or other cardiac disorders.
A client with a history of atrial fibrillation has experienced a TIA. What does the nurse expect will be the priority preventative medical treatment(s) to reduce the risk of a cerebrovascular accident (CVA)? Select all that apply.
- A. Cholesterol-lowering drugs
- B. Anticoagulant therapy
- C. Monthly prothrombin levels
- D. Carotid endarterectomy
- E. Percutaneous transluminal angioplasty
Correct Answer: A,B
Rationale: To manage atherosclerosis and the consequences of cardiac arrhythmias, especially atrial fibrillation, cholesterol-lowering drugs and prophylactic anticoagulant or antiplatelet therapy are prescribed. Prothrombin and international normalized ratio (INR) levels may be prescribed to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque. Similarly, a percutaneous transluminal angioplasty (also called a balloon angioplasty) accompanied by placement of a stent is performed to dilate the carotid artery and increase blood flow to the brain.
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?
- A. Decreased Fluid Volume Risk
- B. Aspiration Risk
- C. Impaired Swallowing
- D. Malnutrition Risk
Correct Answer: C
Rationale: Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.