A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Monitor the client's electrolyte levels.
Perform passive range of motion on each extremity.
Suction saliva from the client's mouth.
Record the client's intake and output.
The Correct Answer is C
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
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Correct Answer is A
Explanation
A. Computerized tomography angiography (CTA) is commonly used to visualize blood vessels and identify any blockages or abnormalities in blood flow that may have contributed to a TIA.
B. While a complete blood count (CBC) may be ordered as part of the general assessment, it is not specific for diagnosing TIA and does not provide information on cerebrovascular issues.
C. A transesophageal echocardiogram (TEE) is used to assess cardiac function and may be indicated in some stroke cases, but it is not the primary diagnostic test for TIA.
D. Prothrombin time (PT) assesses clotting function but is not specific for diagnosing TIA; it may be ordered for other reasons but is not a primary diagnostic tool in this context.
Correct Answer is A
Explanation
A. Autonomic dysreflexia is often triggered by a noxious stimulus, such as bladder distention. Preventing bladder distention by ensuring regular bladder emptying can help prevent the condition.
B. Elevating the client's head is a response to autonomic dysreflexia but does not prevent it from occurring.
C. Providing analgesia for headaches addresses a symptom of autonomic dysreflexia but does not prevent it.
D. Monitoring for elevated blood pressure is important in detecting autonomic dysreflexia once it has started, but it does not prevent it.