Difficulty: Medium
Average Score: 83%
Simulated
Passage / Scenario
Vital SignsNurses' Notes
History and Physical
Orders
1030
ÔÇó Temperature: 99.8┬░F
ÔÇó Heart rate: 98 beats/minute
ÔÇó Respirations: 20 breaths/minute
ÔÇó Blood pressure: 178/89 mmHg
ÔÇó Oxygen saturation: 96% on room air
Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.
Correct answer
D
Rationale
Condition: Transient ischemic stroke (D). Actions: Request CT scan (D), perform NIHSS assessment (E). Parameters: Neurological status (A), blood pressure (C). Rationale: Symptoms and history suggest TIA, requiring imaging and neurological monitoring.