A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity?

A client who has a peripherally inserted central catheter (PICC) in the left arm

A client who has left-sided Bell's palsy

A client who has right-sided weakness due to Parkinson's disease

A client who has a right upper extremity arteriovenous fistula

Answer and Explanation

The Correct Answer is D

Choice A reason: While it is generally advised to avoid taking blood pressure readings from an arm with a PICC line to prevent complications, if the right arm cannot be used, as may be the case with the other clients listed, the nurse may have to use the left arm with extreme caution, ensuring not to disrupt the PICC line.

Choice B reason: Bell's palsy affects facial nerves and does not typically impact the measurement of blood pressure. Therefore, there is no contraindication to using the left arm for a blood pressure reading in a client with left-sided Bell's palsy.

Choice C reason: A client with right-sided weakness due to Parkinson's disease can have their blood pressure taken on the left side if the right side is too weak to provide an accurate reading or if using the right side would cause discomfort to the client.

Choice D reason: For a client with a right upper extremity arteriovenous fistula, typically created for dialysis access, blood pressure measurements should not be taken on that arm to avoid damaging the fistula. Therefore, the left arm should be used for blood pressure readings in this case.

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Correct Answer is C

Explanation

Choice A reason: Anticonvulsants are medications used to prevent seizures. While seizures can occur after a stroke, anticonvulsants are not routinely prescribed unless the patient has a history of seizures or has experienced seizures post-stroke. Therefore, anticonvulsants would not be the standard pharmacologic therapy for all patients being discharged after an ischemic stroke.

Choice B reason: Diuretics are used to remove excess fluid from the body and are commonly prescribed for conditions such as heart failure or high blood pressure. They are not typically used as a standard treatment for ischemic stroke unless the patient has a specific condition that requires fluid management.

Choice C reason: Antithrombotic agents, such as aspirin or clopidogrel, are commonly prescribed to patients after an ischemic stroke to prevent further clot formation and reduce the risk of recurrent strokes. These medications work by inhibiting platelet aggregation and are a key part of secondary prevention in stroke management.

Choice D reason: Opioid analgesics are strong painkillers that are used to treat severe pain. They are not typically prescribed upon discharge for ischemic stroke patients unless there is a specific indication for pain management that cannot be managed with other medications.

A. Instruct the client to avoid eating raw vegetables. B. Initiate a referral for the client to a home health agency. C. Remind the client of the importance of medication adherence. D. Tell the client to avoid places where there are large crowds of people.

Correct Answer is B

Explanation

Choice A reason: Instructing the client to avoid eating raw vegetables may be a precautionary measure due to potential immunosuppression from AIDS, but it does not directly demonstrate advocacy. Advocacy would involve actions that support the client's rights, choices, and interests, and while dietary advice is important, it is not an advocacy action in itself.

Choice B reason: Initiating a referral for the client to a home health agency is a clear demonstration of client advocacy. This action shows that the nurse is taking steps to ensure the client receives the necessary support to manage their condition at home, respecting their wish to maintain independence and quality of life.

Choice C reason: Reminding the client of the importance of medication adherence is part of the nurse's educational role but does not necessarily reflect advocacy. Advocacy would involve more proactive measures to support the client's treatment and care decisions.

Choice D reason: Telling the client to avoid places where there are large crowds of people is good advice to reduce the risk of infections, but it is not an advocacy action. Advocacy involves representing the client's interests and facilitating their choices and access to care.

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A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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