You have a client admitted to the unit having suffered a cerebral vascular accident. You are planning the plan of care for the client. What nursing diagnosis would be included in the client's plan of care? Select all that apply.
Pain.
Incontinence.
Impaired verbal communication.
Impaired swallowing.
Self-care deficit.
Correct Answer : B,C,D,E
"Impaired verbal communication," "Impaired swallowing," and "Self-care deficit." These are all potential nursing diagnoses for a client who has suffered a cerebral vascular accident. Pain may not be a priority nursing diagnosis in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.
Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.
Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.
Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.
Correct Answer is B
Explanation
Ringing in the ears. Salicylate toxicity or salicylism is a condition that occurs when a client is taking large amounts of salicylates, which can result in symptoms such as tinnitus or ringing in the ears, nausea, vomiting, and diarrhea. Clients should report these symptoms to their healthcare provider immediately to prevent further complications.
Choice A, diarrhea, is not a symptom of salicylate toxicity, but rather a potential side effect of the medication in normal doses.
Choice C, dry eyes, and choice D, dry hacking cough, are not symptoms of salicylate toxicity.
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