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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Pinworm infections can be asymptomatic, so treatment is recommended even in the absence of symptoms to prevent spread.
Choice B reason: A second dose of mebendazole is often recommended two weeks after the initial dose to ensure all pinworms are eliminated, including newly hatched ones.
Choice C reason: Mebendazole is not recommended for children under two years of age without medical advice.
Choice D reason: Mebendazole is typically administered orally, not as a rectal suppository.
Correct Answer is ["B","E"]
Explanation
Choice A reason: Tinnitus is not an immediate concern in the context of multiple sclerosis.
Choice B reason: Tachycardia should be reported immediately as it could indicate an underlying cardiovascular issue or autonomic dysfunction.
Choice C reason: Tremors are a common symptom of multiple sclerosis and do not require immediate reporting unless there is a significant change.
Choice D reason: Paresthesia is also a common symptom of multiple sclerosis and does not require immediate reporting unless there is a significant change.
Choice E reason: Fever should be reported immediately as it can indicate an infection, which can exacerbate multiple sclerosis symptoms.
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