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 C
Explanation
Tinnitus and sensorineural hearing loss. Salicylates, loop diuretics, quinidine, quinine, or aminoglycosides can cause ototoxicity, which includes tinnitus (ringing in the ears) and sensorineural hearing loss. Therefore, the nurse should monitor the client for auditory changes and report them to the healthcare provider immediately.
Option A, impaired facial movement, is incorrect because it is a sign of facial nerve paralysis, which can occur due to Bell's palsy, stroke, or brain injury.
Option B, signs of hypotension, is incorrect because it can be caused by antihypertensive drugs or dehydration, not the drugs listed.
Option D, reduced urinary output, is incorrect because it can be a sign of acute kidney injury or dehydration, not the drugs listed.
Correct Answer is C
Explanation
Ischemic. Imaging studies indicate an occlusion partially obstructing the right carotid artery, which may result in reduced blood flow to the brain, leading to ischemia. Ischemic stroke is caused by a blocked or narrowed artery that supplies blood to the brain.
Option A: Right-sided and Option B: Left-sided are not correct answers as they refer to the location of the stroke, which cannot be determined by the information provided in the question.
Option D: Hemorrhagic is not a correct answer as it is caused by bleeding in the brain, not a blocked or narrowed artery.
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