A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn’t recognize their limitations. Which priority measure should the nurse implement to prevent injury?

Reasoning:

Choice A reason: Extensive burns can trigger DIC through tissue damage and inflammation, releasing procoagulants that activate clotting. However, the risk is lower than in septic shock, as burns primarily cause localized injury, and systemic coagulopathy is less intense unless complicated by secondary infection or severe hypoperfusion.

Choice B reason: Acute respiratory distress syndrome (ARDS) may contribute to DIC through inflammation and hypoxia, but it is not the primary driver. ARDS affects lung function, and coagulopathy is secondary to underlying causes like sepsis, which has a more direct and potent effect on widespread clotting activation.

Choice C reason: Multiple trauma increases DIC risk through tissue injury and blood loss, activating coagulation pathways. However, septic shock has a higher risk due to systemic infection driving intense inflammatory and coagulative responses, consuming platelets and clotting factors more aggressively, leading to a greater likelihood of DIC.

Choice D reason: Septic shock poses the highest DIC risk, as systemic infection triggers massive cytokine release and endothelial damage, activating the coagulation cascade. This leads to widespread microthrombi, consuming platelets and clotting factors, causing both thrombosis and bleeding, making septic shock the most likely precipitant in ICU clients.

Reasoning:

Choice A reason: Homonymous hemianopsia causes loss of half the visual field, affecting object recognition due to visual impairment, not cognitive processing. The client’s need to inspect clothing to identify it suggests a sensory processing deficit, not a visual field loss, making agnosia more likely.

Choice B reason: Receptive aphasia impairs language comprehension, affecting the ability to understand spoken or written words, not object recognition. The client’s ability to identify clothing by inspection, not language, points to a sensory processing issue, ruling out aphasia as the primary impairment.

Choice C reason: Hemiplegia, or paralysis of one side, affects movement, not object recognition. The client’s difficulty identifying clothing is cognitive, not motor, as they can manipulate items but need visual inspection to understand them, indicating agnosia rather than a physical impairment like hemiplegia.

Choice D reason: Agnosia, a post-stroke impairment, prevents recognition of objects despite intact sensory input. The client’s need to inspect clothing to identify it suggests visual agnosia, where the brain fails to process familiar objects, matching the described behavior and indicating a perceptual deficit from stroke.