Question

A nurse is caring for a client in the emergency department who has a preliminary diagnosis of a transient ischemic attack (TIA). Which of the following diagnostic testing should the nurse anticipate the provider to prescribe?

Answer 1

Correct Answers:

Computerized tomography angiography (CTA)

Rationale :

✾ CTA provides detailed images of cerebral blood vessels and is essential in identifying vascular abnormalities, such as stenosis or occlusion.

✾ It is often ordered immediately in clients with suspected TIA to determine the location and extent of compromised blood flow.

✾ This test helps the healthcare team decide if the client is at risk for a stroke, guiding urgent treatment decisions.

✾ Rapid visualization of cerebral circulation is crucial to differentiate TIA from other neurologic emergencies.

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Answer 2

Correct Answers:

Placing padding around or under the patient's head
Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain
Have the necessary equipment and/or personnel in case the patient doesn't spontaneously breath when the seizure is over
Note the time the seizure started

Rationale :

✿ Placing padding around or under the patient's head

🔸 Padding helps protect the patient from head trauma during convulsions.

🔸It cushions any sudden impact if the client falls.

🔸This is a simple yet vital action to reduce seizure-related injuries.

✿ Positioning the patient on the side once the relaxation stage is entered

🔸 Turning the client to their side promotes airway clearance and prevents aspiration.

🔸This is especially important if the client vomits or has oral secretions.

🔸 It supports safer breathing and recovery post-seizure.

✿ Having equipment or personnel ready if the patient doesn't breathe

🔸 It is essential to anticipate postictal respiratory arrest, especially in prolonged seizures.

🔸Having suction, oxygen, or emergency staff on hand ensures prompt intervention.

🔸 This helps prevent complications or hypoxic injury.

✿ Noting the time the seizure started

🔸 Knowing when the seizure began helps determine if it meets criteria for status epilepticus (lasting >5 minutes).

🔸Accurate timing is essential for clinical documentation and response planning.

🔸This also aids in medication evaluation.

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Answer 3

Correct Answers:

The client should maintain systolic BP between 120 and 129 mm Hg.

Rationale :

🍃 Maintaining systolic BP in this range helps reduce the risk of recurrent TIA and stroke.

🍃 According to guidelines, this range ensures adequate perfusion without imposing stress on cerebral vasculature.

🍃 Blood pressure control is a cornerstone of secondary stroke prevention in hypertensive patients.

🍃 Education on home BP monitoring and medication adherence should be part of discharge teaching.

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Answer 4

Correct Answers:

Difficulty initiating speech

Rationale :

🌿 Expressive aphasia (Broca’s) is characterized by non-fluent, labored speech output with preserved comprehension.

🌿 Clients typically know what they want to say but have trouble forming complete sentences.

🌿 Writing and speech are both affected in expressive aphasia due to damage in the left frontal lobe.

🌿 It differs from receptive aphasia, which involves difficulty understanding spoken or written language.

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Answer 5

Correct Answers:

"It is too early to tell. When the spinal shock subsides, we will know more."

Rationale :

🌸 Spinal shock causes temporary flaccid paralysis, masking true neurologic function.

🌸 Once spinal shock resolves, clinicians can assess residual function and prognosis.

🌸 Giving false reassurance or definitive predictions may mislead or distress the family.

🌸 This response communicates truth with compassion, promoting trust and appropriate expectation.

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Answer 6

Correct Answers:

Absence of the Achilles tendon jerk

Rationale :

🌼 Diminished, but not absent, deep tendon reflexes are normal with aging; complete loss is abnormal.

🌼 The absence of the Achilles reflex may suggest peripheral neuropathy or spinal cord pathology.

🌼 A full neuro exam is important to differentiate normal age-related changes from pathology.

🌼 It is essential to document and compare with baseline to determine any decline.

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Answer 7

Correct Answers:

Lie flat.

Rationale :

🌻 Lying flat helps prevent cerebrospinal fluid (CSF) leakage, which can cause severe headache.

🌻 This position maintains intraspinal pressure balance, reducing the risk of post-lumbar puncture headache.

🌻 Clients are usually advised to lie flat for 4–8 hours depending on institutional protocol.

🌻 Adequate hydration and monitoring for neurologic signs are also part of post-procedure care.

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Answer 8

Correct Answers:

Bradycardia, hypertension, and widening pulse pressure

Rationale :

🌺 Cushing’s triad is a late sign of increased ICP and indicates possible brain herniation.

🌺 The combination of bradycardia, hypertension, and widened pulse pressure is due to altered brainstem function.

🌺 It requires immediate action, such as hyperventilation or surgical intervention to reduce ICP.

🌺 Early recognition improves the chance of preventing permanent brain damage.

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Answer 9

Correct Answers:

Semicomatose

Rationale :

🌸 A semicomatose client responds only to painful stimuli, often by withdrawing or grimacing.

🌸 This condition reflects severe depression of the cerebral cortex and demands urgent evaluation.

🌸 It's important to monitor for changes and reassess Glasgow Coma Scale to guide management.

🌸 Continuous assessment supports detection of neurologic deterioration or improvement.

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Answer 10

Correct Answers:

Communication is altered.

Rationale :

❖ ALS progressively impairs the muscles responsible for speech, leading to dysarthria and communication challenges.

❖ As the patient loses the ability to express thoughts and needs, emotional frustration and social withdrawal increase.

❖ This communication barrier contributes significantly to depressive symptoms, especially as mental capacity remains intact.

❖ The awareness of declining verbal interaction often intensifies feelings of helplessness and isolation.

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QLexNursing

1 :
A nurse is caring for a client in the emergency department who has a preliminary diagnosis of a transient ischemic attack (TIA). Which of the following diagnostic testing should the nurse anticipate the provider to prescribe?

2 :
A nurse is reinforcing discharge teaching to a client who has epilepsy. Which of the following instructions should be included in the teaching?

3 :
A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

4 :
Which signs and symptoms characterize expressive aphasia?

5 :
On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?

6 :
Which neurologic finding would be considered abnormal in an 88-year-old patient?

7 :
Which position should a nurse instruct a patient to assume after a lumbar puncture to prevent a headache?

8 :
Which three symptoms are characteristic of Cushing triad associated with increased ICP?

9 :
A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?

10 :
Which reason explains why a patient with amyotrophic lateral sclerosis (ALS) is uniquely prone to depression?

QLexNursing

1 : A nurse is caring for a client in the emergency department who has a preliminary diagnosis of a transient ischemic attack (TIA). Which of the following diagnostic testing should the nurse anticipate the provider to prescribe?

2 : A nurse is reinforcing discharge teaching to a client who has epilepsy. Which of the following instructions should be included in the teaching?

3 : A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

4 : Which signs and symptoms characterize expressive aphasia?

5 : On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?

6 : Which neurologic finding would be considered abnormal in an 88-year-old patient?

7 : Which position should a nurse instruct a patient to assume after a lumbar puncture to prevent a headache?

8 : Which three symptoms are characteristic of Cushing triad associated with increased ICP?

9 : A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?

10 : Which reason explains why a patient with amyotrophic lateral sclerosis (ALS) is uniquely prone to depression?

1 :
A nurse is caring for a client in the emergency department who has a preliminary diagnosis of a transient ischemic attack (TIA). Which of the following diagnostic testing should the nurse anticipate the provider to prescribe?

2 :
A nurse is reinforcing discharge teaching to a client who has epilepsy. Which of the following instructions should be included in the teaching?

3 :
A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?

4 :
Which signs and symptoms characterize expressive aphasia?

5 :
On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. Which is the best response by the nurse?

6 :
Which neurologic finding would be considered abnormal in an 88-year-old patient?

7 :
Which position should a nurse instruct a patient to assume after a lumbar puncture to prevent a headache?

8 :
Which three symptoms are characteristic of Cushing triad associated with increased ICP?

9 :
A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?

10 :
Which reason explains why a patient with amyotrophic lateral sclerosis (ALS) is uniquely prone to depression?