A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

The client is consuming 25% of their meals.

The client coughs frequently while eating.

The client's blood pressure is 142/94 mm Hg.

The client leans to the left side while sitting.

Answer and Explanation

The Correct Answer is B

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

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Correct Answer is A

Explanation

A. Metabolic syndrome:

Metabolic syndrome is a cluster of conditions that increase the risk of cardiovascular disease, diabetes, and stroke. These conditions include elevated blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Individuals with metabolic syndrome are at an increased risk of developing cardiovascular disease.

B. Family history of alcohol use disorder:

While a family history of alcohol use disorder may contribute to various health issues, it is not a direct risk factor for cardiovascular disease. However, excessive alcohol consumption itself can contribute to cardiovascular problems.

C. Hypotension:

Hypotension, or low blood pressure, is generally not considered a risk factor for cardiovascular disease. In fact, low blood pressure is often associated with a reduced risk of certain cardiovascular events.

D. Participation in competitive sports:

Participation in competitive sports, in general, is not a risk factor for cardiovascular disease. In fact, regular physical activity is often recommended for cardiovascular health. However, the specific type and intensity of sports activities, as w

A. Administer the PN and fat emulsion separately. B. Prepare the client for a central venous line. C. Change the PN infusion bag every 48 hr. D. Obtain a random blood glucose daily.

Correct Answer is B

Explanation

A. Administer the PN and fat emulsion separately:

Administering the PN and fat emulsion separately is not a typical practice. Usually, PN formulations are prepared to include both macronutrients (carbohydrates and fat) in a single bag to provide a balanced nutritional profile. Administering them separately might lead to inconsistencies in the client's nutritional intake.

B. Prepare the client for a central venous line:

This is the correct action. Parenteral nutrition (PN) with a high concentration of dextrose (20%) and fat emulsions can be hypertonic and irritating to peripheral veins. Therefore, a central venous line is often recommended for the administration of such solutions. Preparing the client for a central venous line helps ensure the safe and effective delivery of PN.

C. Change the PN infusion bag every 48 hr:

The frequency of changing the PN infusion bag is not solely determined by time but rather by factors such as the stability of the solution, risk of contamination, and compatibility of the components. The specific recommendation for changing the PN bag should be based on institutional policies and the characteristics of the PN solution being used.

D. Obtain a random blood glucose daily:

While monitoring blood glucose is important in clients receiving PN, obtaining a random blood glucose daily is not specific enough for managing the potential hyperglycemic effects of a 20% dextrose solution. Continuous glucose monitoring or more frequent and scheduled blood glucose checks may be necessary.

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A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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