NCLEX-RN · Question #486
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She…
The correct answer is A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of. (A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary tomaintenance of an effective airway. (C) While prevention of injury is important…
Question
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She isunable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Options
- AIneffective airway clearance related to immobility, ineffective cough, and decreased level of
- BAltered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
- CPotential for injury related to impaired mobility and seizures
- DImpaired verbal communication related to aphasia
How the community answered
(67 responses)- A79% (53)
- B3% (2)
- C13% (9)
- D4% (3)
Explanation
(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary tomaintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is notlife threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
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