Physiological Adaptation Practice Question

Question

The nurse is caring for a client with heart failure and is focused on stroke changes scenario 2. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Delegate the clinical assessment and nursing judgment to assistive personnel.
3. C. Document the concern without notifying the appropriate provider or care team member when escalation is needed.
4. D. Recognize neurologic changes and maintain aspiration precautions.

Correct Answer

D. Recognize neurologic changes and maintain aspiration precautions.

Explanation

The priority action for stroke changes is to recognize neurologic changes and maintain aspiration precautions. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: hard
• Domain: Physiological Adaptation
• Objective: stroke changes

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