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 A

Explanation

A. tPA is not delivered for hemorrhagic stroke: This is correct. tPA is a thrombolytic medication used for ischemic strokes, not haemorrhagic strokes, as it would exacerbate bleeding.
B. The total effects of ischemia are not currently known: While assessing the extent of ischemia is important for ischemic stroke, it is irrelevant here because the stroke is hemorrhagic.
C. Too much time has passed since the symptoms began: The time window is important for tPA in ischemic strokes, but in this case, the type of stroke (haemorrhagic) is the determining factor.
D. The patient's symptoms have progressed too quickly: The progression of symptoms does not affect the decision to use tPA; the contraindication is solely due to the hemorrhagic nature of the stroke.

A. Computed tomography B. Duplex ultrasound C. Ankle-brachial index D. Troponin T E. Electrocardiogram

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

Explanation

A. Computed tomography: CT angiography can visualize the arteries and detect blockages or narrowing, making it useful in diagnosing peripheral arterial disease (PAD).
B. Duplex ultrasound: This test combines traditional ultrasound with Doppler to assess blood flow and the structure of blood vessels, which is useful for diagnosing PAD by identifying areas of reduced blood flow or blockages.
C. Ankle-brachial index: The ankle-brachial index (ABI) is a non-invasive test that compares the blood pressure in the ankle with the blood pressure in the arm to detect reduced blood flow in the legs, indicative of PAD.
D. Troponin T: Troponin T is a biomarker used to diagnose myocardial infarction (heart attack) and is not relevant for diagnosing PAD, which involves peripheral arteries.
E. Electrocardiogram: An electrocardiogram (ECG) measures the electrical activity of the heart and is used to diagnose cardiac issues, not peripheral artery disease.

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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

Correct Answer is A

Explanation

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

Explanation

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