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","B","C","D","E"]

Explanation

Choice A reason: Orthostatic hypotension is a common issue in PD and requires interventions to prevent falls.

Choice B reason: Stooped posture is characteristic of PD and affects mobility and balance.

Choice C reason: Bradykinesia (slowness of movement) is a hallmark of PD and impacts daily activities and mobility.

Choice D reason: Muscular rigidity is a key symptom of PD and affects the client's ability to move freely.

Choice E reason: A shuffling, propulsive gait is typical in PD and requires interventions to ensure safety and improve mobility.

A. Recommend that the client's family return to the area to help provide assistance. B. Advise to have a case management evaluation of the client's home environment. C. Suggest contacting social services to help find a respite care facility for her husband. D. Tell her to consider hiring a private nurse during the postoperative convalescence.

Correct Answer is B

Explanation

Choice A reason: Recommending that the client's family return to the area to help provide assistance is not always feasible and may place undue stress on the family. It is also not a sustainable long-term solution.

Choice B reason: Advising a case management evaluation of the client's home environment is the best response as it allows for a comprehensive assessment of the client's needs and resources. The case manager can help coordinate care, arrange for necessary services, and provide support for both the client and her husband.

Choice C reason: Suggesting contacting social services to help find a respite care facility for her husband is a reasonable option, but it may not be the most immediate or suitable solution for the client’s concerns. This option should be considered as part of the overall case management plan.

Choice D reason: Telling her to consider hiring a private nurse during the postoperative convalescence may be helpful, but it can be costly and may not be necessary if other support systems are in place. It should be discussed as part of the case management evaluation.

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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 Parkinson's disease (PD) is admitted to the medical surgical unit and the nurse assesses the client's mobility needs. Which finding(s) indicate the need to plan interventions related to the client's mobility? Select all that apply.

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

Explanation

Correct Answer is B

Explanation

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