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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because issues related to the digestive system are not likely to be caused by UTIs or constipation. Digestive system issues can include gastritis, ulcers, irritable bowel syndrome, or inflammatory bowel disease, which can cause symptoms such as abdominal pain, nausea, vomiting, diarrhea, or bleeding. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice B reason: This is incorrect because vitamin B12 deficiency is not likely to be caused by UTIs or constipation. Vitamin B12 deficiency can occur due to poor dietary intake, malabsorption, or pernicious anemia, which can cause symptoms such as fatigue, weakness, numbness, tingling, or anemia. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice C reason: This is incorrect because malnutrition is not likely to be caused by UTIs or constipation. Malnutrition can occur due to inadequate food intake, poor food quality, or increased nutritional needs, which can cause symptoms such as weight loss, muscle wasting, edema, or poor wound healing. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice D reason: This is correct because dehydration can be caused by UTIs or constipation. UTIs can cause increased urination, fever, or vomiting, which can lead to fluid loss and dehydration. Constipation can cause reduced fluid intake, hard stools, or straining, which can also lead to fluid loss and dehydration. Dehydration can cause symptoms such as dry mouth, thirst, low urine output, dark urine, or low blood pressure. Dehydration can also worsen UTIs or constipation, creating a vicious cycle. Therefore, dehydration is a possible condition that the client might be suffering from.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Isolated systolic hypertension is not a result of end-organ damage from chronic hypertension, but rather a risk factor for it. Isolated systolic hypertension is a condition where the systolic blood pressure is elevated (>140 mmHg) while the diastolic blood pressure is normal (<90 mmHg). It is common in older adults due to the stiffening of the arteries, and can increase the risk of cardiovascular and cerebrovascular events.
Choice B reason: Atrial fibrillation is a result of end-organ damage from chronic hypertension. Atrial fibrillation is an irregular and often rapid heart rate that can cause poor blood flow and increase the risk of stroke and heart failure. Chronic hypertension can damage the heart muscle and the electrical system of the heart, leading to atrial fibrillation.
Choice C reason: Renal insufficiency is a result of end-organ damage from chronic hypertension. Renal insufficiency is a condition where the kidneys are unable to filter waste and fluid from the blood adequately. Chronic hypertension can damage the blood vessels and the nephrons of the kidneys, leading to renal insufficiency.
Choice D reason: Stroke is a result of end-organ damage from chronic hypertension. Stroke is a sudden interruption of blood supply to the brain, causing brain cell death and neurological deficits. Chronic hypertension can damage the blood vessels in the brain, making them prone to rupture (hemorrhagic stroke) or blockage (ischemic stroke).
Choice E reason: Cardiac disease is a result of end-organ damage from chronic hypertension. Cardiac disease is a broad term that encompasses various disorders of the heart, such as coronary artery disease, heart attack, heart failure, and cardiomyopathy. Chronic hypertension can damage the heart by increasing the workload and the oxygen demand of the heart, causing the heart to enlarge and weaken over time.
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