After completing an admission assessment on a client who recently experienced a stroke, the nurse should choose which of the following nursing diagnoses as a priority?

Risk for injury

Altered cerebral perfusion

Decreased mobility

Altered thought process

Answer and Explanation

The Correct Answer is B

Choice A reason: Risk for injury is a potential nursing diagnosis for a client who recently experienced a stroke, but it is not the priority. Risk for injury is related to the possible complications of stroke, such as hemiparesis, hemiplegia, dysphagia, or sensory deficits, that may increase the risk of falls, aspiration, or pressure ulcers. However, these complications are secondary to the primary problem of altered cerebral perfusion, which is the cause of stroke.

Choice B reason: Altered cerebral perfusion is the priority nursing diagnosis for a client who recently experienced a stroke, because it is the most urgent and life-threatening problem. Altered cerebral perfusion is defined as a decrease in blood flow to the brain, which can result in ischemia, infarction, or hemorrhage of the brain tissue. This can lead to irreversible neurological damage, disability, or death. Therefore, the nurse should focus on restoring and maintaining adequate cerebral perfusion as the first priority.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A: Pressure ulcers - Physical restraints can lead to immobility, which increases the risk of pressure ulcers due to prolonged pressure on the skin.

Choice B: Death - Restraints can cause fatal accidents. For example, a person might try to remove the restraint, fall, and suffer a fatal injury.

Choice C: Sepsis - While sepsis is a severe condition often caused by an infection, it's not a direct result of physical restraints. However, if a pressure ulcer (caused by restraints) becomes severely infected, it could potentially lead to sepsis.

Choice D: Decreased circulation/perfusion to the extremities - Restraints can restrict movement, leading to decreased blood flow to the extremities.

Choice E: Fractures - Struggling against restraints can lead to falls and subsequent fractures.

A. It should only be given to individuals who have never had an episode of Herpes Zoster (HZ). B. It is recommended for all individuals over age 50 that have no contraindications to the vaccine. C. It should not be given to anyone with a chronic cardiac or respiratory condition. D. It will always prevent an individual from developing Herpes Zoster.

Correct Answer is B

Explanation

Choice A reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals who have had a previous episode of Herpes Zoster (HZ), as long as they are not currently experiencing an acute outbreak. The vaccine can help prevent future recurrences of HZ, as well as reduce the risk of postherpetic neuralgia, a painful complication of HZ.
Choice B reason: This statement is correct because the zoster vaccine Shingrix is recommended for all individuals over age 50 that have no contraindications to the vaccine, such as a history of severe allergic reaction to any component of the vaccine, or a current severe immunodeficiency. The vaccine can help prevent HZ and its complications, which are more common and severe in older adults.
Choice C reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals with a chronic cardiac or respiratory condition, as long as they are not immunocompromised. The vaccine is not a live vaccine, so it does not pose a risk of causing or worsening the underlying condition. The vaccine can help protect the individuals from HZ and its complications, which can exacerbate their condition or interfere with their treatment.
Choice D reason: This statement is incorrect because the zoster vaccine Shingrix does not always prevent an individual from developing Herpes Zoster. The vaccine has a high efficacy rate of about 90%, but it is not 100%. The vaccine can reduce the severity and duration of HZ, as well as the risk of postherpetic neuralgia, if it does occur.

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After completing an admission assessment on a client who recently experienced a stroke, the nurse should choose which of the following nursing diagnoses as a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client has been admitted to a skilled nursing facility. Which of the following can be caused by physical restraints? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is providing an educational session on vaccines to a group of older adults. The nurse is discussing the zoster vaccine Shingrix. Which of the following information should the nurse include in the education?

Correct Answer is B

Explanation

When an older female adult client complains of itching and pain and several days later shows you a rash, what do you realize she has?

Which factors in the patient care environment should be routinely assessed to decrease the risk of falls? (Select all that apply.)

The older adult who is diagnosed with type 2 diabetes mellitus has a sensory impairment and unstable blood sugar levels. Which of the following alterations in sensory function does the nurse address in the plan of care for stabilizing the blood sugar?

According to Healthy People 2020, older adults have been identified as a priority, addressing goals to improve dental health. Identify the correct dental health goals for older adults. (Select all that apply.)

The nurse uses comfort measures to enhance an older adult's pharmacological pain management. Which of the following would be most helpful for the nurse to use to identify the relationships between the comfort measures, activity, and pharmacotherapy, and the older adult's pain level?

Some things that you, as the nurse, might teach your client to help control urinary incontinence include which of the following (Select all that apply)?

For a cognitively impaired patient who cannot accurately report pain, which assessment tool would be most useful?