A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.
Which of the following information is the priority for the nurse to discuss?
Choosing an agency to provide home physical therapy.
Obtaining an alert system to get help in case of a fall.
Providing information about available transportation resources.
Reviewing information about support groups for individuals who have had a stroke.
The Correct Answer is B
Choice A rationale:
Choosing an agency to provide home physical therapy is important, but it is not the priority in this situation. The client's safety and immediate needs should be addressed first.
Choice B rationale:
Obtaining an alert system to get help in case of a fall is the priority for an older adult living alone with left-sided weakness following a stroke. Falls can result in serious injuries, so having an alert system ensures the client can call for assistance promptly, enhancing their safety and well-being.
Choice C rationale:
Providing information about available transportation resources is important for the client's long-term independence and quality of life. However, immediate safety concerns, such as the risk of falls, should be addressed first.
Choice D rationale:
Reviewing information about support groups for individuals who have had a stroke is essential for the client's emotional well-being and social support. However, immediate safety measures, such as fall prevention, take precedence in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
Choice A rationale:
Contractures are a risk for this client due to the lack of movement and constant positioning on one side. Contractures occur when the muscles, tendons, or ligaments shorten and tighten, limiting range of motion and flexibility. This can be a result of prolonged immobility or lack of use of the muscles.
Choice B rationale:
Calcium resorption is not a risk for this client. Calcium resorption refers to the process where bone tissue is broken down and calcium is released into the bloodstream. This process is not directly related to immobility or multiple sclerosis.
Choice C rationale:
Hypocalcemia, or low calcium levels in the blood, is also not a direct risk for this client. While immobility can lead to bone loss over time, it does not directly cause hypocalcemia.
Choice D rationale:
Diarrhea is not a risk for this client based on the information provided. Diarrhea can be a symptom of many conditions but there is no indication in the scenario that this client is at risk.
Choice E rationale:
Urinary stasis is a risk for this client due to their immobility. When a person is immobile, urine can pool in the bladder, creating an environment where bacteria can grow, potentially leading to urinary tract infections.
Correct Answer is A
Explanation
Choice A rationale:
Dysphagia (difficulty swallowing) is a common complication of esophageal cancer and can lead to malnutrition and aspiration pneumonia. It is the priority finding because addressing the client's ability to swallow is essential for maintaining adequate nutrition and preventing complications.
Choice B rationale:
Xerostomia (dry mouth) is another common side effect of radiation therapy, but while uncomfortable, it does not pose an immediate risk to the client's health compared to dysphagia.
Choice C rationale:
Excoriation of the skin on the neck and chest is likely due to the radiation therapy and can be managed with appropriate skin care measures. Although important, it is not the priority compared to dysphagia.
Choice D rationale:
The client's self-reported pain level of 6 on a scale from 0 to 10 is concerning and requires attention, but addressing dysphagia takes precedence due to its potential impact on the client's nutritional status and overall well-being.
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