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NCLEX-RN · Question #486
NCLEX-RN Question #486: Real Exam Question with Answer & Explanation
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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
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