NCLEX Neurologic and Sensory Systems Practice Exam

In the case of an unconscious client admitted after a cerebrovascular accident (CVA), the priority nursing concern is respiratory distress. This is due to the fact that unconscious patients are at a higher risk for airway compromise. The loss of consciousness can impede the ability to maintain a patent airway, which may lead to inadequate ventilation and oxygenation. Monitoring the respiratory status is crucial, as any compromise can result in severe hypoxia or respiratory failure.

The need to ensure that the airway is protected and that the client is maintaining adequate respiration is critical in the acute phase after a CVA. Interventions such as assessing the airway, providing oxygen, or initiating suctioning in case of secretions are vital nursing priorities.

While concerns like injury, constipation, and decreased fluid volume are important and should be addressed, they do not take precedence over ensuring adequate respiratory function in an unconscious patient. Ensuring the airway is clear and that the client is breathing effectively is fundamental to prevent further complications and support their recovery.