While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

Alteration in body image

Alteration in activity tolerance

Impaired tissue perfusion

Impaired skin integrity

Answer and Explanation

The Correct Answer is C

Impaired tissue perfusion is a nursing diagnosis that indicates a decrease in oxygen and nutrient delivery to the tissues, resulting in cellular dysfunction and potential tissue damage or necrosis. It is the priority nursing diagnosis for a client who has varicose veins with ulcerations and lower extremity edema, as these are signs of chronic venous insufficiency, which is a condition in which the veins in the legs fail to return blood to the heart eﬀectively, causing blood to pool and stagnate in the lower extremities. This leads to increased venous pressure, inﬂammation, and impaired wound healing, which can cause skin breakdown, infection, and tissue necrosis. The nurse should monitor the client's vital signs, peripheral pulses, capillary refill, skin color, temperature, and sensation, and implement interventions to improve venous return and prevent further complications, such as elevating the legs, applying compression stockings, encouraging ambulation, administering medications, and providing wound care.

Alteration in body image. This is a nursing diagnosis that indicates a negative perception or dissatisfaction with one's physical appearance or function. It may be applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these may aﬀect their self-esteem and social interactions. However, it is not the priority nursing diagnosis for this client, as it does not pose an immediate threat to their health or safety.

Alteration in activity tolerance. This is a nursing diagnosis that indicates a decrease in the ability to perform physical activities without experiencing fatigue, dyspnea, or other symptoms. It may be applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these may limit their mobility and endurance. However, it is not the priority nursing diagnosis for this client, as it does not pose an immediate threat to their health or safety.

Impaired skin integrity. This is a nursing diagnosis that indicates a disruption or damage to the epidermis or dermis layers of the skin. It is applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these can cause skin breakdown and infection. However, it is not the priority nursing diagnosis for this client, as it is a consequence of impaired tissue perfusion, which is the underlying problem that needs to be addressed first.

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Correct Answer is C

Explanation

A hemorrhagic stroke is a type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. A common cause of hemorrhagic stroke is a cerebral aneurysm, which is a weak or bulging spot in an artery wall. When an aneurysm ruptures, it causes sudden and severe bleeding in the brain, which can damage brain cells and increase intracranial pressure. Symptoms of a hemorrhagic stroke include a sudden and severe headache, often described as "the worst headache of my life", followed by neurologic deficits, such as weakness, numbness, vision loss, speech problems, confusion, or loss of consciousness
The other options are not correct because:
History of neurologic deficits lasting less than 1 hr. This statement is incorrect because it describes a transient ischemic atack (TIA), which is a temporary interruption of blood ﬂow to the brain that causes brief neurologic symptoms that resolve within 24 hours. A TIA is often a warning sign of an impending ischemic stroke, which is a type of stroke that occurs when a blood clot blocks an artery in the brain and reduces blood ﬂow to the aﬀected area.
Maintains consciousness. This statement is incorrect because most clients with hemorrhagic stroke lose consciousness or have altered mental status due to the increased intracranial pressure and brain damage caused by the bleeding. The level of consciousness depends on the location and extent of the hemorrhage, but it usually deteriorates rapidly.
Gradual onset of several hours. This statement is incorrect because hemorrhagic stroke usually has a sudden onset, unlike ischemic stroke, which may have a gradual onset over several hours or days. The onset of hemorrhagic stroke is often associated with physical exertion, emotional stress, or hypertension, which can increase the risk of aneurysm rupture.

A. Hold the client's arms and legs from moving. B. Place the client back in bed. C. Place the client on his side. D. Insert a tongue blade in the client's mouth.

Correct Answer is C

Explanation

Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.

Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.

Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the ﬂoor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.

Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse enters a client's room and finds the client on the ﬂoor having a seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse include?

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?

A nurse is preparing to administer valproic acid 400 mg PO bid for migraine headaches. Available is valproic acid 250 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?