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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.
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A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks. What instructions should the nurse give this client?
- A. Identify and avoid factors that precipitate or intensify an attack.
- B. Keep a record of activities following an attack.
- C. When an attack occurs, stay in a brightly lit area.
- D. Write down any adverse drug effects.
Correct Answer: A
Rationale: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs whenever possible.
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.
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.
A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client?
- A. Blood pressure 180/98 mm Hg
- B. Alert and oriented times three
- C. Grade V on the Hunt-Hess Scale
- D. Complaint of severe splitting headache
Correct Answer: C
Rationale: The Hunt-Hess Scale is used for grading a client with a cerebral aneurysm and provides the most accurate assessment as listed. An elevated blood pressure is anticipated with a cerebral aneurysm. Being alert and oriented provides little assessment value without additional neurologic data. Complaint of severe headache is subjective and not as significant as results from using the Hunt-Hess Scale.
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.