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 C

Explanation

Choice A reason: Assessing color, warmth, movement, and sensation of extremities is relevant for neurological or vascular conditions, not a fluid deprivation test. This test induces dehydration to evaluate ADH function, which primarily affects fluid status and cardiovascular parameters, not peripheral limb function, making these assessments less critical for monitoring during the test.

Choice B reason: Breath and bowel sounds are not prioritized during a fluid deprivation test. The test assesses the body’s ability to concentrate urine under dehydration stress, primarily impacting fluid and cardiovascular status. Respiratory and gastrointestinal functions are not directly affected by short-term fluid restriction in diagnosing diabetes insipidus.

Choice C reason: Heart rate and blood pressure are critical during a fluid deprivation test, as dehydration from fluid restriction can cause hypovolemia, leading to tachycardia and hypotension. Monitoring these parameters ensures patient safety and detects cardiovascular responses to fluid loss, which are key to evaluating the severity of diabetes insipidus.

Choice D reason: Temperature and oxygen saturation are secondary in a fluid deprivation test. Dehydration may cause slight temperature changes, but these are not primary indicators. Oxygen saturation remains stable unless severe hypovolemia leads to shock, which is rare in a controlled setting, making these assessments less critical than cardiovascular monitoring.

A. Third-spacing and hyperthermia B. Bradycardia and hypertension C. Tachycardia and agitation D. Respiratory distress and projectile vomiting

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Third-spacing and hyperthermia are not typical of autonomic dysreflexia, a condition in spinal cord injury causing sympathetic overactivity. Third-spacing occurs in fluid shifts like edema, and hyperthermia suggests infection, not the autonomic response to stimuli like bladder distension triggering dysreflexia.

Choice B reason: Autonomic dysreflexia, common in spinal cord injuries above T6, causes bradycardia and hypertension. Noxious stimuli (e.g., bladder distension) trigger sympathetic overactivity, raising blood pressure, while baroreceptors stimulate vagal response, slowing heart rate, making these classic manifestations of this life-threatening condition.

Choice C reason: Tachycardia and agitation may occur in other conditions but are not primary in autonomic dysreflexia. Hypertension triggers a compensatory bradycardia, not tachycardia, and while agitation may accompany distress, the hallmark is the cardiovascular response, making this less accurate.

Choice D reason: Respiratory distress and projectile vomiting are not primary manifestations of autonomic dysreflexia. While severe hypertension may cause nausea, the classic signs are bradycardia and hypertension due to sympathetic overactivity from stimuli below the spinal injury, not respiratory or vomiting issues.

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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 health care provider has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?

Correct Answer is C

Explanation

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Correct Answer is B

Explanation

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