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

Diarrhea. A client who is recovering from bariatric surgery and is eating from a portable commode is at risk for diarrhea. Diarrhea can cause fluid and electrolyte imbalances, leading to dehydration, which can be life-threatening, especially in the immediate postoperative period.

Option A, impaired mobility, would not be a priority concern in the immediate postoperative period for this client.

Option B, impaired gas exchange, is not related to the situation.

Option C, self-care deficit, maybe a concern but is not as significant as diarrhea in the immediate postoperative period.

A. Palpate gently without repeated attempts. B. Not palpate the thyroid and just listen for a bruit. C. Palpate firmly in order to feel the thyroid gland. D. Continue to palpate the gland until it is felt for enlargement.

Correct Answer is A

Explanation

Palpate gently without repeated attempts. Palpating the thyroid gland can stimulate the release of thyroid hormone, which can result in a thyroid storm, a potentially life-threatening condition characterized by a rapid heart rate, fever, and high blood pressure. Therefore, the nurse should be careful not to overstimulate the thyroid gland.

Not palpating the thyroid and just listening for a bruit (B) is not a sufficient assessment of the thyroid gland. Palpating the gland firmly in order to feel it for enlargement (C) can be too stimulating and increase the risk of thyroid hormone release. Continuing to palpate the gland until it is felt for enlargement (D) is not necessary and may result in overstimulation of the gland.

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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

A client, who is recovering from bariatric surgery, is eating from a po [portable commode]. Nursing assessment is of greatest concern in the immediate postoperative period for which of the following?

Correct Answer is D

Explanation

The nurse is performing an assessment of the thyroid gland. In order to decrease the risk that the nurse will stimulate the release of large amounts of thyroid hormone, what should the nurse be sure to do?

Correct Answer is A

Explanation

The nurse is caring for a client who has had a fracture reduction using a cast. Which of the following would be most important for the nurse to assess before and after the cast application?

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