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 A

Explanation

Reasoning:

Choice A reason: The posterior pituitary gland is the primary site involved in SIADH, as it releases antidiuretic hormone (ADH). Excessive ADH secretion causes water retention, leading to hyponatremia. In SIADH, dysregulation of ADH release, often due to ectopic production or pituitary overstimulation, is the core pathophysiological mechanism.

Choice B reason: The anterior pituitary gland produces hormones like growth hormone and ACTH, not ADH. It is not involved in SIADH, which is specifically related to excessive ADH from the posterior pituitary or ectopic sources, causing water retention and dilutional hyponatremia, distinct from anterior pituitary functions.

Choice C reason: The thyroid gland regulates metabolism through thyroid hormones, not fluid balance. SIADH is caused by excessive ADH, which is unrelated to thyroid function. Thyroid disorders may cause metabolic symptoms but do not contribute to the water retention seen in SIADH.

Choice D reason: The adrenal gland produces cortisol and aldosterone, which regulate stress responses and sodium balance, not ADH. SIADH involves excessive ADH, leading to water retention, and is unrelated to adrenal function. Adrenal disorders like Addison’s disease affect sodium differently, not via ADH.

A. To detect evidence of infection such as fever and tachycardia B. To detect evidence of dehydration that might have triggered a sickle cell crisis C. To detect abnormal sounds suggestive of acute respiratory complications and/or heart failure D. To detect motor strength and stroke-related signs and symptoms

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Detecting infection via fever and tachycardia is important in sickle cell anemia, but auscultation of lungs and heart is not primarily for these signs. Fever is assessed by temperature, and tachycardia by pulse, not stethoscope. Auscultation focuses on organ-specific complications like respiratory or cardiac issues, not systemic signs.

Choice B reason: Dehydration can trigger sickle cell crises, but auscultation of lungs and heart does not directly assess hydration status. Fluid status is evaluated through vital signs, skin turgor, or urine output, not heart or lung sounds, making this response less accurate for the purpose of auscultation.

Choice C reason: Auscultating lungs and heart in sickle cell anemia detects abnormal sounds indicating acute respiratory complications, like acute chest syndrome, or heart failure from chronic anemia or vaso-occlusion. Crackles, wheezes, or murmurs suggest these complications, making this the most accurate explanation for the child’s question.

Choice D reason: Motor strength and stroke-related signs are assessed through neurological exams, not lung or heart auscultation. While stroke is a risk in sickle cell anemia due to vaso-occlusion, auscultation targets cardiopulmonary complications, not motor or neurological deficits, making this response inappropriate.

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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

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?

Correct Answer is A

Explanation

A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be the best response by the nurse?

Correct Answer is C

Explanation

A client with sickle cell anemia has a:

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