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: Infection is not directly related to tissue hypoxia in iron deficiency anemia. Hypoxia results from low hemoglobin, reducing oxygen delivery, but it does not inherently cause infection. Infections may contribute to anemia in chronic disease but are not the primary issue in iron deficiency.

Choice B reason: Deficient fluid volume is not a primary concern in iron deficiency anemia. Impaired erythropoiesis reduces red blood cell production due to low iron, causing anemia, but fluid volume remains normal unless bleeding occurs. Fatigue from low oxygen capacity is more directly linked to the condition.

Choice C reason: Acute pain is not typical in iron deficiency anemia. Pain is associated with hemolytic anemias like sickle cell disease due to vaso-occlusion. Iron deficiency causes fatigue and dyspnea from low hemoglobin, not hemolysis or pain, making this an incorrect association.

Choice D reason: Fatigue related to decreased oxygen-carrying capacity is the most likely issue in iron deficiency anemia. Low iron impairs hemoglobin synthesis, reducing red blood cell oxygen transport, causing tissue hypoxia and fatigue, especially during exertion, directly reflecting the pathophysiology of the client’s condition.

A. Bundle branch block B. Ventricular tachycardia C. Supraventricular tachycardia D. Atrial fibrillation

Correct Answer is D

Explanation

Reasoning:

Choice A reason: Bundle branch block affects ventricular conduction but does not typically cause emboli. It may lead to dyssynchrony but lacks the stasis in the atria that promotes clot formation, making it less associated with cardiogenic embolic strokes compared to atrial fibrillation’s thrombus-forming mechanism.

Choice B reason: Ventricular tachycardia is a life-threatening arrhythmia affecting the ventricles, causing hemodynamic instability but not typically embolic strokes. It does not promote atrial stasis or clot formation, which are necessary for cardiogenic emboli to travel to the brain, unlike atrial fibrillation.

Choice C reason: Supraventricular tachycardia causes rapid heart rates above the ventricles but is less likely to form atrial clots than atrial fibrillation. It does not typically cause the prolonged stasis needed for thrombus formation, making it less associated with embolic strokes in the brain.

Choice D reason: Atrial fibrillation is strongly associated with cardiogenic embolic strokes. It causes irregular atrial contractions, leading to blood stasis in the atria, promoting thrombus formation. These clots can embolize to the brain, causing ischemic stroke, making it a key risk factor requiring anticoagulation.

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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

An adult client has been diagnosed with iron deficiency anemia. Which is most likely based on this client’s health status?

Correct Answer is D

Explanation

A preceptor discussing stroke with a new nurse on the unit would tell the new nurse that which cardiac dysrhythmia is associated with cardiogenic embolic strokes?

Correct Answer is D

Explanation

Which type of hemolytic anemia is categorized as an inherited disorder?

A client has just been diagnosed with an aneurysm. When planning discharge teaching for this client, what instructions should the nurse provide to the client?

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, “This is how I know what item I am holding.” What impairment is this client likely experiencing?

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