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","C","E"]

Explanation

A. Monitor blood glucose levels: Patients with diabetes need to keep their blood glucose levels under control to prevent complications, including those that can exacerbate hypertension or lead to cardiovascular problems.
B. Lifestyle modifications and medication adherence will not prevent blindness: This is incorrect. Proper management of diabetes through lifestyle changes and medication adherence can help prevent complications like diabetic retinopathy, which can lead to blindness.
C. Lifestyle modifications can prevent strokes: Effective management of diabetes and hypertension through lifestyle changes (diet, exercise, smoking cessation) can significantly reduce the risk of strokes and other cardiovascular events.
D. End organ damage is inevitable because of microvascular changes that occur: This is misleading. While microvascular changes are a risk in diabetes, proper management and lifestyle modifications can greatly reduce the risk and progression of end-organ damage.
E. Take medications as ordered: Adherence to prescribed medications is crucial for controlling both blood glucose and blood pressure, reducing the risk of complications such as stroke, heart disease, and kidney damage.

A. Women often have vague symptoms of stroke such as weakness or hallucinations. B. The FAST acronym stands for Face, Arms, Swallowing, and Time. C. Stroke patients always present with dysphasia. D. Treatment that begins within 3 hours of symptom onset can minimize or avoid permanent loss of function.

Correct Answer is D

Explanation

A. Women often have vague symptoms of stroke such as weakness or hallucinations: While women may sometimes present with less typical symptoms, stating that hallucinations are common is misleading. Stroke symptoms in women can vary, but weakness and other neurological deficits are more common.
B. The FAST acronym stands for Face, Arms, Swallowing, and Time: This is incorrect. FAST stands for Face (drooping), Arms (weakness), Speech (difficulty), and Time (importance of quick action).
C. Stroke patients always present with dysphasia: This is incorrect. Not all stroke patients have speech difficulties; symptoms vary depending on the area of the brain affected.
D. Treatment that begins within 3 hours of symptom onset can minimize or avoid permanent loss of function: This is correct. Timely intervention, especially with treatments like tPA for ischemic strokes, can significantly reduce the extent of brain damage and improve outcomes.

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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

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Correct Answer is D

Explanation

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