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    HESI RN EXIT PROCTORED EXAMQuestion 91
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    HESI RN EXIT PROCTORED EXAM

    When admitting a client with a diagnosis of transient ischemic attack (TIA, which intervention is most important for the nurse to include in this client's plan of care?

    Explanation & Rationale

    A. Initiating neurological monitoring every 2 hours is critical for a client with a TIA. This allows for early detection of any changes in neurological status, which could indicate worsening conditions or the onset of a stroke. Monitoring helps ensure prompt intervention if symptoms escalate. B. While assessing bilateral breath sounds is important for overall respiratory function, it is not the most urgent priority in managing a TIA. Neurological assessments take precedence in this situation. C. Reviewing the client's daily medications is important for understanding potential risk factors and management, but it is a secondary intervention. Neurological monitoring takes priority in the acute phase of care for a TIA. D. Palpating the suprapubic region for urinary retention is more relevant in clients at risk for retention due to neurological or urological issues but is not a primary concern in managing a TIA. The focus should be on neurological function.

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