A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client’s home environment, the nurse should focus on which nursing diagnosis?

Reasoning:

Choice A reason: A chest radiograph evaluates lung or cardiac issues but is not the first test for symptoms of tiredness, coldness, and shortness of breath with tachycardia. These suggest anemia, and a CBC directly assesses hemoglobin and red blood cell counts, making it more relevant than imaging for initial evaluation.

Choice B reason: An ECG assesses cardiac rhythm and ischemia, useful for tachycardia, but it does not address the underlying cause of fatigue, coldness, and dyspnea. These symptoms suggest anemia, and a CBC is needed to confirm low hemoglobin before evaluating cardiac function with an ECG.

Choice C reason: A complete blood count (CBC) is the most appropriate test, as tiredness, coldness, shortness of breath, and tachycardia suggest anemia. A CBC measures hemoglobin, hematocrit, and red blood cell indices, identifying anemia’s presence and type, guiding further diagnostic and therapeutic interventions for the client’s symptoms.

Choice D reason: Antibiotics treat infections, but tiredness, coldness, dyspnea, and tachycardia point to anemia, not infection. Without fever or infection signs, antibiotics are inappropriate. A CBC is needed to confirm anemia as the cause, making it the priority over empirical antibiotic therapy.

Reasoning:

Choice A reason: Systolic blood pressure above 70 mm Hg is a goal in hypovolemia but is not the most specific outcome for DIC-related bleeding. While low blood pressure reflects fluid loss, addressing bleeding directly prevents further volume depletion, making reduced bleeding a more targeted and measurable outcome.

Choice B reason: A stable level of consciousness is important but not directly tied to deficient fluid volume from bleeding in DIC. Altered consciousness may result from cerebral ischemia or hyponatremia, but reducing bleeding is the primary goal to stabilize fluid volume and prevent further hemodynamic compromise.

Choice C reason: Urine output of 30 mL/hour or more indicates adequate renal perfusion but is a secondary outcome in DIC-related bleeding. While it reflects fluid status, directly addressing bleeding through interventions like transfusions or clotting factor replacement is more specific to correcting the underlying fluid volume deficit.

Choice D reason: Decreased bleeding is the most appropriate outcome for deficient fluid volume in DIC, as bleeding from mucosal and venipuncture sites directly causes volume loss. Reducing hemorrhage through platelet or factor replacement stabilizes fluid volume, preventing hypovolemia and its complications, making this the most measurable and relevant outcome.