A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

"This unit has a policy against staff harassment."

"It is important to dress the right arm first."

"Dressing must be a frustrating experience for you."

"We will give you a class on dressing tomorrow."

Monitor the client's white blood cell count.

Answer and Explanation

The Correct Answer is C

A. "This unit has a policy against staff harassment."

This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.

B. "It is important to dress the right arm first."

This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.

C. "Dressing must be a frustrating experience for you."

This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.

D. "We will give you a class on dressing tomorrow."

This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.

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Correct Answer is B

Explanation

A. Assess strength of deep tendon reflexes:

Hyperkalemia can affect neuromuscular function, leading to alterations in deep tendon reflexes. However, determining the apical pulse rate and rhythm is more crucial as hyperkalemia can cause cardiac dysrhythmias and cardiac arrest.

B. Determine apical pulse rate and rhythm:

This is the most important intervention because hyperkalemia can lead to life-threatening cardiac dysrhythmias, including ventricular tachycardia and ventricular fibrillation. Monitoring the apical pulse rate and rhythm allows the nurse to detect any abnormalities promptly.

C. Compare muscle strength bilaterally:

Hyperkalemia can cause muscle weakness or paralysis due to its effects on neuromuscular function. While assessing muscle strength is important, monitoring cardiac function takes precedence because of the potential for life-threatening dysrhythmias.

D. Observe color and amount of urine:

Hyperkalemia can affect renal function, leading to changes in urine output and composition. While monitoring urine output and characteristics is important for assessing renal function, it is not the most critical intervention when managing acute hyperkalemia and its potential cardiac effects.

A. Provide a back rub at bedtime. B. Leave the door to the client's room open slightly. C. Apply wrist restraints to prevent wandering. D. Administer a PRN sedative prescription.

Correct Answer is A

Explanation

A. Provide a back rub at bedtime:

This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.

B. Leave the door to the client's room open slightly:

Leaving the door open may not prevent wandering and could potentially lead to safety issues.

C. Apply wrist restraints to prevent wandering:

Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.

D. Administer a PRN sedative prescription:

Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.

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A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Correct Answer is A

Explanation

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