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?

Risk for injury

Ineffective coping

Noncompliance

Diarrhea

Answer and Explanation

The Correct Answer is A

Reasoning:

Choice A reason: Risk for injury is the priority for a client with left-sided hemiparesis post-stroke. Weakness on one side impairs mobility and balance, increasing fall risk. Home environment assessment ensures removal of hazards like rugs or clutter, promoting safety and preventing injuries, critical for stroke recovery.

Choice B reason: Ineffective coping may occur post-stroke due to emotional or functional challenges, but it is not the primary focus during home environment assessment. Physical safety from falls due to hemiparesis is more immediate, as coping issues are addressed through counseling, not environmental modifications.

Choice C reason: Noncompliance with treatment may affect stroke recovery but is not directly addressed by home environment assessment. Ensuring a safe environment to prevent falls due to hemiparesis takes precedence, as physical safety is critical before addressing behavioral or adherence issues in discharge planning.

Choice D reason: Diarrhea is unrelated to hemiparesis or home environment assessment post-stroke. It may occur from medications or other causes but does not pose an immediate risk like falls. The focus is on preventing injuries due to mobility issues, not gastrointestinal symptoms, in this context.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Continuous oxygen therapy is not a standard preventive measure for sickle cell crises. Oxygen is used during acute crises to treat hypoxia from vaso-occlusion, but daily hydration is more effective for prevention, as it reduces blood viscosity and sickling, making this inappropriate.

Choice B reason: Avoiding all sports is overly restrictive for sickle cell anemia. Moderate exercise can be safe with proper hydration and rest. Complete avoidance does not directly prevent crises and may reduce quality of life, whereas hydration directly addresses the risk of sickling and vaso-occlusion.

Choice C reason: Avoiding activities causing shortness of breath is partially correct, as overexertion can trigger hypoxia and crises. However, it is less specific than hydration, which directly reduces blood viscosity and sickling, preventing crises more effectively across various situations, not just during exertion.

Choice D reason: Drinking at least 8 glasses of water daily is critical in sickle cell anemia to prevent crises. Adequate hydration reduces blood viscosity, preventing red blood cell sickling and vaso-occlusion. Dehydration increases sickling risk, making consistent fluid intake a key preventive strategy for this client.

A. To determine the cause of the TIA B. To remove atherosclerotic plaques blocking cerebral flow C. To prevent seizure activity that is common following a TIA D. To decrease cerebral edema

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Carotid endarterectomy (CEA) does not determine the cause of TIAs but treats them by removing plaques. Diagnostic tests like carotid ultrasound identify atherosclerosis as the cause. CEA addresses the known obstruction, preventing further ischemic events, not investigating their etiology.

Choice B reason: CEA removes atherosclerotic plaques from the carotid artery, restoring blood flow to the brain. TIAs often result from plaque-induced stenosis, causing transient ischemia. By clearing the blockage, CEA prevents recurrent TIAs and strokes, directly addressing the underlying cause of cerebral hypoperfusion.

Choice C reason: Preventing seizure activity is not the purpose of CEA. Seizures are not common after TIAs, which are transient ischemic events without permanent damage. CEA targets vascular stenosis to prevent ischemia, not neurological complications like seizures, which are unrelated to its mechanism.

Choice D reason: Decreasing cerebral edema is not a goal of CEA. Edema is more associated with hemorrhagic stroke or severe ischemia, not TIAs. CEA restores blood flow by removing plaques, preventing ischemic events, not addressing brain swelling, which requires different interventions like mannitol.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 13-year-old diagnosed with sickle cell anemia. The client asks the nurse what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client?

Correct Answer is D

Explanation

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy (CEA). The nurse explains that this procedure will be done for what purpose?

Correct Answer is B

Explanation

Which is a clinical manifestation of diabetes insipidus?

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