You have a client admitted to the unit having suffered a cerebral vascular accident. You are planning the plan of care for the client. What nursing diagnosis would be included in the client's plan of care? Select all that apply.

Pain.

Incontinence.

Impaired verbal communication.

Impaired swallowing.

Self-care deficit.

Answer and Explanation

Correct Answer : B,C,D,E

"Impaired verbal communication," "Impaired swallowing," and "Self-care deficit." These are all potential nursing diagnoses for a client who has suffered a cerebral vascular accident. Pain may not be a priority nursing diagnosis in this situation.

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Correct Answer is D

Explanation

Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.

Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.

Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.

Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.

A. Previous sexually transmitted infection (STI). B. Cryptorchidism as an infant. C. Low sperm count.

Correct Answer is B

Explanation

cryptorchidism as an infant. Cryptorchidism, or undescended testicles, is a known risk factor for testicular cancer. During fetal development, the testicles form in the abdomen and descend into the scrotum before birth. Failure of one or both testicles to descend into the scrotum can increase the risk of testicular cancer later in life. Therefore, a history of cryptorchidism as an infant is the most important assessment finding to identify clients at higher risk of developing testicular cancer.

Choice A, previous sexually transmitted infection (STI), is incorrect because although STIs can increase the risk of certain types of cancer, they are not a significant risk factor for testicular cancer.

Choice C, low sperm count, is incorrect because although low sperm count can be associated with testicular cancer, it is not a reliable indicator for determining a higher risk for testicular cancer. Low sperm count may also be caused by various other factors, such as hormonal imbalances, infections, varicocele, and genetic abnormalities. While it is important to monitor and treat low sperm count, it is not a definitive indicator of testicular cancer risk.

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You have a client admitted to the unit having suffered a cerebral vascular accident. You are planning the plan of care for the client. What nursing diagnosis would be included in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client had a nasogastric tube placed two days ago. Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?

Correct Answer is D

Explanation

Which assessment finding is most important in determining which client has a higher risk for developing testicular cancer?

Correct Answer is B

Explanation

The nurse is checking the blood glucose of a client and has a reading of 48. The client is not easily awakened and only responds with a groan. What will the nurse administer to raise the blood glucose level?

When performing pin care, which of the following would be most appropriate? Select all that apply.

A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of leaking of cerebral spinal fluid (CSF)?

The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as normal finding for this age group?

During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

The nurse is planning care for a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?

A client experiences a musculoskeletal injury that involves the structure that connects a muscle to the bone. The nurse understands that this injury involves which of the following?