Nokea
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.
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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.
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 experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy?
- A. Encourage deep breathing and coughing.
- B. Observe for facial swelling.
- C. Anticipate need for endotracheal intubation.
- D. Resume antilipemic drugs.
Correct Answer: C
Rationale: Surgical approach to the neck area can result in swelling and blockage of the airway. This is especially significant with bilateral carotid endarterectomy. The nurse must be observant and prepared for immediate intubation if the airway becomes obstructed. Encouraging deep breathing and coughing is not significant because general anesthesia is not routine. Resuming drugs for hyperlipidemia is not a priority in the acute postoperative period.
The nurse is assessing a client for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests that the client is experiencing a TIA?
- A. Impaired muscle coordination
- B. Respiratory distress
- C. Severe headache
- D. Nausea and vomiting
Correct Answer: A
Rationale: A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?
- A. Ischemic
- B. Hemorrhagic
- C. Right-sided
- D. Left-sided
Correct Answer: A
Rationale: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.