A client who had a stroke is being transferred from the intensive care unit (ICU) to a rehabilitation unit. The ICU nurse is giving a handoff report to the rehabilitation nurse.

Which information should be included in the report?

The client's vital signs, laboratory results, and medications.

The client's medical history, diagnosis, and prognosis.

The client's functional status, goals, and discharge plan.

The client's preferences, family involvement, and psychosocial needs.

Answer and Explanation

The Correct Answer is C

The client's functional status, goals, and discharge plan.

Rationale: The client's functional status, goals, and discharge plan are relevant information for the rehabilitation nurse, as they provide a baseline for assessing progress and planning interventions. The rehabilitation nurse will focus on helping the client regain function and independence, as well as preparing for discharge.

Incorrect options:

A) The client's vital signs, laboratory results, and medications. - This is not relevant information for the rehabilitation nurse, as these are routine data that can be obtained from other sources, such as electronic records or charts. The rehabilitation nurse will monitor these parameters as needed, but they are not essential for planning care.

B) The client's medical history, diagnosis, and prognosis. - This is not relevant information for the rehabilitation nurse, as these are general data that can be obtained from other sources, such as electronic records or charts. The rehabilitation nurse will be aware of these factors, but they are not specific for planning care.

D) The client's preferences, family involvement, and psychosocial needs. - This is not relevant information for the rehabilitation nurse, as these are subjective data that can be obtained from direct communication with the client and family. The rehabilitation nurse will address these aspects as part of holistic care, but they are not critical for planning care.

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Correct Answer is B

Explanation

To prevent lactic acidosis due to contrast dye

Rationale: Metformin is an oral antidiabetic agent that lowers blood glucose levels by decreasing hepatic glucose production and increasing peripheral glucose uptake. However, metformin can cause lactic acidosis, a rare but serious condition that occurs when lactate accumulates in the blood faster than it can be metabolized. Lactic acidosis can be triggered by contrast dye used for radiographic procedures, such as colonoscopy, especially in clients who have renal impairment or dehydration. Therefore, metformin should be discontinued 48 hours before and after any procedure that involves contrast dye.

Incorrect options:

A) To prevent hypoglycemia during fasting - This is not the rationale for discontinuing metformin, as metformin does not cause hypoglycemia by itself. However, the client may need to adjust the dose of other antidiabetic medications or insulin to prevent hypoglycemia during fasting.

C) To prevent hyperglycemia due to stress response - This is not the rationale for discontinuing metformin, as metformin does not cause hyperglycemia by itself. However, the client may need to monitor blood glucose levels more frequently and report any signs of hyperglycemia to the provider.

D) To prevent nephrotoxicity due to dehydration - This is not the rationale for discontinuing metformin, as metformin does not cause nephrotoxicity by itself. However, the client should be advised to maintain adequate hydration before and after the procedure to prevent dehydration and renal impairment.

A. Fever B. Headache C. Nuchal rigidity D. Photophobia

Correct Answer is C

Explanation

Nuchal rigidity

Rationale: Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and indicates inflammation of the meninges, the membranes that cover the brain and spinal cord. Kernig's sign is a test that involves flexing the client's hip and knee at 90 degrees and then attempting to straighten the leg. A positive Kernig's sign is when the client experiences pain or resistance in the hamstring muscles, indicating meningeal irritation.

Incorrect options:

A) Fever - This is a nonspecific sign of infection and inflammation and does not indicate meningitis specifically.

B) Headache - This is a common symptom of meningitis, due to the increased intracranial pressure caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

D) Photophobia - This is a common symptom of meningitis, due to the sensitivity of the optic nerve to light caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

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A client who had a stroke is being transferred from the intensive care unit (ICU) to a rehabilitation unit. The ICU nurse is giving a handoff report to the rehabilitation nurse. Which information should be included in the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has diabetes mellitus is scheduled for a colonoscopy. The nurse instructs the client to stop taking metformin 48 hours before and after the procedure. What is the rationale for this instruction?

Correct Answer is B

Explanation

A client is admitted to the hospital with suspected meningitis. Which assessment finding should alert the nurse to perform a Kernig's sign test?

Correct Answer is C

Explanation

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A client who had a stroke is being transferred from the intensive care unit (ICU) to a rehabilitation unit. The ICU nurse is giving a handoff report to the rehabilitation nurse. Which information should be included in the report?

A client who had a stroke is being transferred from the intensive care unit (ICU) to a rehabilitation unit. The ICU nurse is giving a handoff report to the rehabilitation nurse.

Which information should be included in the report?