The nurse is caring for a patient suffering from left-sided hemianopsia after having a stroke. Which nursing diagnosis is priority for this patient?
Incontinence (bowel or urinary)
Impaired skin integrity
Disturbed sensory perception
Imbalanced nutrition
The Correct Answer is C
A. Incontinence (bowel or urinary): While incontinence may occur in stroke patients, it is not the primary concern for someone with hemianopsia, a visual impairment.
B. Impaired skin integrity: Although this is important, particularly for immobile patients, it is not directly related to hemianopsia.
C. Disturbed sensory perception: Hemianopsia results in the loss of half the field of vision in one or both eyes, leading to disturbed sensory perception. This is a priority because it directly affects the patient's ability to navigate their environment safely.
D. Imbalanced nutrition: Although important, this is not the immediate concern related to hemianopsia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Impaired Physical Mobility: This is not directly related to hypertension management. While hypertension can affect physical activity, it is not the primary focus in the context of managing high blood pressure.
B. Readiness for Enhanced Health Literacy: This is the correct focus. Educating the patient about hypertension management, lifestyle modifications, and medication adherence is crucial in managing and controlling blood pressure.
C. Decreased Activity Tolerance: This could be a related issue but is not the primary focus. It addresses the impact of hypertension on physical capacity rather than managing the condition itself.
D. Ineffective Airway Clearance: This is unrelated to hypertension. It focuses on respiratory issues rather than blood pressure management.
Correct Answer is B
Explanation
A. Ensure an adequate potassium blood level.: While potassium levels are important, they are not the primary goal in a hypertensive emergency.
B. Gradually reduce BP.: In hypertensive emergencies, the goal is to gradually reduce blood pressure to avoid causing further damage to organs. Rapid reduction can lead to ischemia or stroke.
C. Negate the impact of sodium in the body.: Although reducing sodium intake is a general recommendation for hypertension management, it is not the immediate goal in an emergency situation.
D. Increase urine output.: While diuretics might be used, the main goal is the controlled reduction of blood pressure rather than just increasing urine output.
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