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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
During a seizure, the nurse's priority is to ensure the client's safety by protecting them from injury. The nurse should loosen any tight clothing and move furniture or objects that may harm the client. The client should be turned onto their side to prevent aspiration, and suctioning the mouth is not indicated during the seizure. Restraints are not appropriate during a seizure, and inserting a tongue blade between the teeth can cause injury.
Correct Answer is D
Explanation
"From birth through puberty." This period is the time of most rapid bone growth and development, which is crucial for the nurse to understand when educating clients on growth and development. Choices A, B, and C are not correct because they do not correspond with periods of bone growth and development.
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