A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn’t recognize their limitations. Which priority measure should the nurse implement to prevent injury?

Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies

Ask a health care provider to order a vest and wrist restraints

Encourage the family to reprimand the client if they don’t ask for help with transfers and mobility

Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed

Answer and Explanation

The Correct Answer is D

Reasoning:

Choice A reason: Encouraging independence without assistance in an impulsive client post-hemorrhagic stroke increases fall risk. Their lack of insight into limitations heightens injury potential. A bed alarm is safer, as it alerts staff to assist, preventing falls due to unrecognized motor or cognitive deficits.

Choice B reason: Ordering restraints like vests or wrist restraints is not the first choice, as they restrict autonomy and may increase agitation in an impulsive client. Non-invasive measures like bed alarms are preferred to prevent injury while preserving dignity and promoting safe mobility post-stroke.

Choice C reason: Encouraging family to reprimand the client for not seeking help may increase emotional distress and does not prevent injury. It fails to address impulsive behavior directly. A bed alarm proactively alerts staff to assist, reducing fall risk more effectively than behavioral reprimands.

Choice D reason: Installing a bed alarm is the priority to prevent injury in an impulsive client post-hemorrhagic stroke. It alerts staff when the client attempts to move unassisted, compensating for their lack of insight into limitations, reducing fall risk, and ensuring timely assistance for safe mobility.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Diabetes insipidus causes hypernatremia due to excessive water loss from ADH deficiency, leading to polyuria and dehydration. This increases serum sodium concentration, not dilutional hyponatremia, which is characterized by low sodium due to water retention, making DI incorrect for this condition.

Choice B reason: Hypothyroidism affects metabolism through low thyroid hormone levels, causing symptoms like fatigue and weight gain. It does not directly cause dilutional hyponatremia, as it does not involve ADH or water retention. Sodium imbalances in hypothyroidism are rare and not dilutional in nature.

Choice C reason: Hyperthyroidism increases metabolism but does not typically cause dilutional hyponatremia. It may lead to dehydration from increased metabolic demand, but this does not involve excessive water retention or ADH dysfunction, which are necessary for dilutional hyponatremia to occur.

Choice D reason: SIADH causes dilutional hyponatremia due to excessive ADH, leading to water retention in the kidneys. This dilutes serum sodium, lowering its concentration. The increased fluid volume without corresponding sodium retention is the hallmark of SIADH, making it the correct endocrine disorder.

A. Place the client’s clock on the affected side B. Place the client’s extremities where the client can see them C. Approach the client on the side where vision is impaired D. Keep the lighting in the client’s room low

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Placing the clock on the affected side (left in right-sided stroke) worsens hemianopsia issues, as the client cannot see the left visual field. This increases neglect and disorientation. Positioning items in the intact visual field helps the client compensate for the visual deficit effectively.

Choice B reason: Placing extremities in the client’s intact visual field (right side in right-sided stroke) compensates for left hemianopsia. This helps the client maintain awareness of their body, reducing neglect and injury risk, as they cannot see the left side, improving safety and sensory integration.

Choice C reason: Approaching from the impaired side (left in right-sided stroke) increases disorientation and neglect in hemianopsia. Approaching from the intact right side ensures the client can see and respond, improving communication and reducing startle or confusion caused by unseen approaches.

Choice D reason: Keeping lighting low may reduce glare but does not address hemianopsia’s visual field loss. Adequate lighting in the intact field enhances visibility of objects and extremities, aiding compensation for the deficit. Low lighting could increase disorientation in clients with visual impairments.

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A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn’t recognize their limitations. Which priority measure should the nurse implement to prevent injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which endocrine disorder causes the client to have dilutional hyponatremia?

Correct Answer is D

Explanation

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How can the nurse help the client manage potential sensory and perceptual difficulties?

Correct Answer is B

Explanation

Which outcome indicates that treatment of a client with diabetes insipidus has been effective?

A nurse is providing care to a client diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse understands that the primary problem involves which gland?

A client is ordered desmopressin (DDAVP) for the treatment of diabetes insipidus. What therapeutic response does the nurse anticipate the client will experience?

A client comes to the clinic reporting fatigue. Laboratory findings reveal a low serum iron level, a low transferrin saturation, and a low ferritin level. Which type of anemia does the nurse suspect that correlates with these laboratory findings?

For a client with Hodgkin disease who has developed neutropenia, what is an appropriate nursing intervention to include in the care plan?

A client has been placed on corticosteroid therapy for Addison's disease. The nurse should be aware of which of the following side effects associated with this type of therapy? (Select all that apply)

A client had gastric bypass surgery 3 years ago and now, experiencing fatigue, visits the clinic to determine the cause. The client takes pantoprazole for the treatment of frequent heartburn. What type of anemia is this client at risk for?

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse’s best intervention for preventing injury?