PN Adult Medical Surgical Practice Exam

Which of the following is a priority nursing diagnosis for a client who just had a stroke?

1. Imbalanced nutrition: less than body requirements.

2. Risk for impaired skin integrity.

3. Acute confusion.

4. Altered mobility.

The correct answer is: Altered mobility.

In the context of a client who has just experienced a stroke, the priority nursing diagnosis focuses on the most immediate and critical needs of the patient. After a stroke, patients often face significant challenges with mobility due to motor impairment, weakness, or paralysis on one side of the body. This altered mobility can greatly impact their ability to perform activities of daily living and increases the risk of complications such as falls, contractures, and increased dependence on caregivers. Addressing altered mobility also encompasses other aspects of care, such as preventing complications from immobility (for example, pressure ulcers and deep vein thrombosis) and promoting rehabilitation. Mobility can directly affect respiratory function, circulation, and overall recovery post-stroke. Therefore, ensuring the patient has appropriate support and interventions to address mobility challenges becomes a priority. While other diagnoses like imbalanced nutrition, risk for impaired skin integrity, and acute confusion are important and may require attention, altered mobility stands out as a priority because it has immediate implications for safety, independence, and overall functional recovery after a stroke.