The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

The client's blood pressure readings will be less than 160/90 mm Hg.

The nurse will encourage the client to walk thirty minutes every day.

The client's family will repeat signs and symptoms about the disease.

The client's daily blood pressure will be less than 140/80 mm Hg this month.

Answer and Explanation

The Correct Answer is D

A. While controlling blood pressure is important in managing cardiovascular disease, the specific outcome should reflect the target blood pressure goal of less than 140/80 mm Hg to reduce the risk of complications.

B. Encouraging physical activity is beneficial for cardiovascular health, but the outcome should focus on blood pressure management, which is more directly related to the client's reported symptoms of blurred vision.

C. Educating the client's family about signs and symptoms of cardiovascular disease is important for support, but it does not directly address the client's blurred vision or cardiovascular risk factors.

D. Achieving a daily blood pressure reading of less than 140/80 mm Hg is an appropriate outcome to ensure adequate control of blood pressure and reduce the risk of cardiovascular complications, including those that may contribute to blurred vision.

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Correct Answer is D

Explanation

A. Increasing anxiety may require intervention, but it does not pose an immediate threat to the client's health compared to other options.

B. Inappropriate laughter could indicate emotional lability, a common symptom in ALS, but it does not typically require immediate intervention unless it's accompanied by other concerning symptoms.

C. Asymmetrical weakness is common in ALS but may not necessarily warrant immediate intervention unless it is significantly affecting the client's ability to perform essential functions.

D. Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.

A. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. B. Administer aspirin to prevent further clot formation and platelet clumping. C. Verify prescribed laboratory tests include prothrombin time and platelet count. D. Maintain elevated positioning of the dependent joints on affected side.

Correct Answer is A

Explanation

A. Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is essential in the immediate management of a client with sudden, severe headache and neurological deficits suggestive of stroke. Time- sensitive interventions, such as IV fibrinolytic therapy, may be indicated if the client meets criteria for treatment.

B. Administering aspirin to prevent further clot formation and platelet clumping is contraindicated in the acute management of a suspected stroke until hemorrhagic stroke is ruled out.

C. Verifying prescribed laboratory tests include prothrombin time and platelet count is important for assessing coagulation status, but it is not the immediate intervention needed in this situation.

D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority intervention in the acute management of a suspected stroke.

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The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

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