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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Altering modifiable risk factors is a good goal for anyone who wants to improve their health and wellness, but it is not specific to the case of the African American man who already has a normal blood pressure and no apparent health problems. Modifiable risk factors are those that can be changed by lifestyle choices, such as smoking, diet, exercise, stress, or alcohol consumption.
Choice B reason: Maintaining tight glycemic control is a relevant goal for people who have diabetes or prediabetes, as it can help prevent or delay the complications of high blood sugar, such as nerve damage, kidney damage, or eye damage. However, there is no indication that the African American man has diabetes or prediabetes, so this goal is not applicable to him.
Choice C reason: Recognizing disease in its early stages is a general goal for everyone who wants to prevent or treat health problems, but it is not specific to the case of the African American man who has no signs or symptoms of any disease. Moreover, this goal is more reactive than proactive, as it implies waiting for disease to occur rather than preventing it.
Choice D reason: Preventing cardiovascular disease is the best goal for the nurse to use to assist the African American man in maintaining his health and wellness into older age, as it is specific, proactive, and evidence-based. According to the American Heart Association, high blood pressure is a major risk factor for cardiovascular disease, and it is more prevalent and severe among African Americans than other racial groups. Therefore, the nurse would advise the African American man to monitor his blood pressure regularly, follow a healthy diet, exercise moderately, avoid smoking, and take medication if needed to prevent cardiovascular disease.
Correct Answer is C
Explanation
Choice A reason: Older African American women do not have the highest risk of suicide among older adults. According to the CDC, suicide rates are highest among adults age 75 and older, and highest among males age 75 and older.
Choice B reason: Older adults and younger adults do not manifest suicidal intent in a similar manner. Older adults tend to plan suicide more carefully, use more lethal means, and have fewer warning signs than younger adults.
Choice C reason: A major crisis experienced by the client can contribute to the risk of suicide. Older adults may face various stressors, such as bereavement, loneliness, chronic illness, or loss of independence, that can trigger suicidal thoughts or behavior.
Choice D reason: Ethics do not require that the nurse respects a person’s intent to terminate his or her own life. Nurses have a duty to protect the safety and well-being of their clients, and to intervene if they suspect suicidal risk.
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