A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

The client requires reinforcement of teaching about the purpose of his medications.

The client is unable to grasp eating utensils.

The client requests to perform ADLS later in the day.

The client tells the nurse he prefers a snack before bedtime.

Answer and Explanation

The Correct Answer is B

This issue indicates a potential difficulty with fine motor skills and may impact the client's ability to feed themselves independently.

It is important for the interprofessional team, including occupational therapy and/or physical therapy, to be aware of this issue and collaborate on appropriate interventions to improve the client's functional abilities and promote independence in activities of daily living (ADLs).

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Correct Answer is A

Explanation

Pain in the calf can be a potential symptom of deep vein thrombosis (DVT), which is a serious complication after surgery. Monitoring the client's pulse oximetry can help assess for signs of decreased oxygenation, which may indicate a possible clot or compromised circulation. A decrease in oxygen saturation can be an early indicator of a potential DVT-related complication, such as a pulmonary embolism. Monitoring the pulse oximetry can provide valuable information for timely intervention and management.

Instructing the client to massage the calf gently is not advisable without further assessment and evaluation. Massaging the calf can potentially dislodge a clot if one is present, leading to further complications. It is important to rule out DVT through appropriate diagnostic measures before providing specific instructions for calf massage.

Maintaining the leg in a dependent position while in bed can potentially worsen the symptoms and increase the risk of venous stasis. Elevating the affected leg, rather than maintaining it in a dependent position, can help improve venous return and reduce pain or swelling.

Applying a cold compress to the client's calf is not recommended without further assessment. Heat or cold therapy should be applied based on the underlying cause of the pain. In the case of potential DVT, applying a cold compress can increase vasoconstriction and potentially worsen the condition. It is essential to investigate the cause of the pain first and consult with the healthcare provider before initiating any specific therapies or interventions.

A. "I understand that immunizations will be withheld if my child has lactose intolerance." B. "I can make several office visits, so my child does not get so many immunizations at once." C. "It is recommended that my child receive his first flu immunization at the age of 6." D. "My child will need to start the human papillomavirus series when he enters kindergarten."

Correct Answer is B

Explanation

This statement demonstrates an understanding of the concept of spacing out immunizations to reduce the number of shots given during a single visit. By making multiple office visits, the parent can ensure that their child receives the recommended immunizations while minimizing the number of injections at each visit.

Lactose intolerance is not a contraindication to receiving immunizations. Most vaccines do not contain lactose, and even if they do, the amount present is typically minimal and not expected to cause an adverse reaction in individuals with lactose intolerance.

The first flu immunization is typically recommended for children starting at 6 months of age, not at 6 years of age.

The human papillomavirus (HPV) vaccine is typically recommended for preteens and adolescents, usually starting between the ages of 11 and 12. It is not typically administered when a child enters kindergarten.

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A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is 2 days postoperative and reports pain in their calf. Which of the following actions should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following client statements indicates an understanding of the nurse's instructions?

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?

A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include?

A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hour creatinine clearance test. Which of the following statements should the nurse include in the teaching?