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

Answer and Explanation

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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Correct Answer is B

Explanation

A. A patient with a BP of 170/80 mm Hg with a mild headache: Although high, this BP is not as immediately critical as 180/120 mm Hg. The patient is experiencing only a mild headache, indicating less urgency.
B. A patient with a BP of 180/120 mm Hg who is asymptomatic: This BP level indicates a hypertensive crisis, which can lead to life-threatening complications such as stroke or heart attack, even if the patient is asymptomatic. Immediate intervention is needed to lower the BP safely.
C. A patient with a BP of 150/60 mm Hg who is anxious: This BP is elevated but not critically so. Anxiety management may be necessary but is not as urgent as managing a hypertensive crisis.
D. A patient with a blood pressure (BP) of 140/70 mm Hg who has a nosebleed: This BP is relatively mild compared to 180/120 mm Hg and is less immediately threatening, even with a nosebleed.

A. Paresthesia B. Pruritus C. Pain D. Pallor E. Palpitations

Correct Answer is ["A","C","D"]

Explanation

A. Paresthesia: Numbness or tingling sensations (paresthesia) can occur due to decreased blood supply and nerve function.
B. Pruritus: Itching (pruritus) is not typically associated with arterial occlusion. It is more often related to skin conditions or allergies.
C. Pain: Pain is a hallmark symptom of arterial occlusion, often described as severe and sudden, due to tissue ischemia.
D. Pallor: Affected limbs or areas may appear pale (pallor) because of reduced blood flow.
E. Palpitations: Palpitations are not a direct symptom of arterial occlusion. They are more related to cardiac conditions.

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The nurse is caring for a patient suffering from left-sided hemianopsia after having a stroke. Which nursing diagnosis is priority for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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