Exam NCLEX-RN topic 4 question 223 discussion

Actual exam question from Test Prep's NCLEX-RN

Question #: 223
Topic #: 4

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 is unable 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?

A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
B. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
C. Potential for injury related to impaired mobility and seizures
D. Impaired verbal communication related to aphasia

Show Suggested Answer

Suggested Answer: A 🗳️
(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 to maintenance 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 not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.

by [deleted] at March 10, 2025, 6:57 a.m.

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Exam NCLEX-RN topic 4 question 223 discussion

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