A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Keep the room brightly lit while providing care.

Minimize verbal interaction with the client.

Monitor for change in speech.

Avoid dropping side rails or abruptly closing the door.

Report any change in level of consciousness.

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Keeping the room brightly lit while providing care may help with orientation but is not a specific instruction related to stroke care.

Choice B reason: Minimizing verbal interaction with the client is not advisable. Communication is essential in assessing the client's neurological status.

Choice C reason: Monitoring for change in speech is important as speech difficulties can indicate a worsening of the stroke or other neurological issues.

Choice D reason: Avoiding dropping side rails or abruptly closing the door helps minimize unnecessary stimulation and agitation, which can be beneficial for a client experiencing a stroke.

Choice E reason: Reporting any change in level of consciousness is critical as it can indicate changes in the client's condition that require immediate medical attention.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

A. Research the religion on different social media platforms. B. Consult with a nurse who shares the same religious beliefs. C. Explain that every client will receive the same high level of care. D. Ask the client about individual care preferences.

Correct Answer is D

Explanation

Choice A reason: Researching the religion on social media is not a reliable or appropriate method for understanding individual care needs.

Choice B reason: Consulting with a nurse who shares the same religious beliefs may provide insight but does not address the specific concerns of the client.

Choice C reason: Explaining that every client receives the same high level of care does not address the client's individual religious needs and concerns.

Choice D reason: Asking the client about individual care preferences ensures that the nurse understands and respects the client's specific religious beliefs and practices.

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A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

Correct Answer is D

Explanation

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

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An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes which pathology as the cause of the symptoms?

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