A nurse is planning care for a client who has had a recent cerebrovascular accident (CVA). Which of the following actions should the nurse include in the plan of care to decrease the client's risk for footdrop?

Apply a sequential compression device.

Use padded splints.

Elevate the extremity above the heart.

Reposition the client every 2 hr.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Apply a sequential compression device: A sequential compression device (SCD) is used to prevent deep vein thrombosis (DVT), not foot drop. It does not provide the necessary support for preventing foot drop, which results from muscle weakness or paralysis after a CVA.

B. Use padded splints: Padded splints help maintain the foot in a neutral position, which is essential in preventing foot drop. Foot drop occurs due to weakness of the dorsiflexor muscles, and splints can prevent the foot from falling into an abnormal position, reducing the risk of deformities.

C. Elevate the extremity above the heart: Elevating the extremity above the heart is typically done to reduce edema, not to prevent foot drop. While elevating the limb can help with swelling, it does not address the muscle weakness that causes foot drop in post-CVA patients.

D. Reposition the client every 2 hr: Repositioning the client every 2 hours is important for preventing pressure ulcers and promoting circulation. However, it is does not prevent foot drop, which requires targeted interventions such as splints or exercises to maintain proper foot positioning.

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Correct Answer is ["C","D","E","G"]

Explanation

Rationale:

A. Blood glucose level: The blood glucose level of 103 mg/dL is within normal limits (74 to 106 mg/dL) and does not require immediate follow-up. While the client has type 2 diabetes mellitus, the blood glucose is not abnormal at this time.

B. Bowel sounds: Bowel sounds are present in all four quadrants and do not require immediate follow-up. This finding is normal and is unrelated to the acute symptoms being assessed for a possible myocardial infarction.

C. Blood pressure: The client’s blood pressure is elevated at 164/80 mm Hg, which requires immediate attention in the context of chest pain and other symptoms that may suggest an acute myocardial infarction (MI).

D. Pain level: The client rates their chest pain as 7 out of 10, which is significant and consistent with potential myocardial ischemia or infarction. The pain’s radiation to the left arm, along with other symptoms like nausea and diaphoresis, suggest an urgent need for intervention.

E. Electrocardiogram findings: The 12-lead ECG shows tachycardia, ST segment elevation, and T wave changes, which are indicative of acute myocardial injury, such as an ST-elevation myocardial infarction (STEMI). This requires immediate intervention to prevent further myocardial damage.

F. Lung sounds: The lung sounds are clear in all lobes, which is reassuring and does not indicate an immediate concern.

G. Troponin T level: The elevated Troponin T level (0.40 ng/mL) is a key biomarker for myocardial injury. The elevation indicates ongoing cardiac damage, which requires immediate follow-up to assess for the extent of the infarction and initiate treatment.

A. Check the client's airway and level of consciousness. B. Assess vital signs to determine hydration status. C. Administer prescribed IV fluids. D. Monitor for pulmonary edema.

Correct Answer is ["A","B","C","D"]

Explanation

Rationale:

A. Check the client's airway and level of consciousness: The first priority is to assess the client's airway and level of consciousness to ensure that they are breathing properly and to gauge the severity of the condition.

B. Assess vital signs to determine hydration status: After assessing the airway and consciousness, it’s crucial to evaluate vital signs to determine the client's hydration status, as dehydration is a significant concern in diabetic ketoacidosis.

C. Administer prescribed IV fluids: IV fluids should be administered promptly to treat dehydration, restore electrolyte balance, and help improve circulation. This is typically the next step after assessing vital signs and hydration status.

D. Monitor for pulmonary edema: Once the IV fluids are being administered, the nurse should monitor for potential complications, such as pulmonary edema, which can occur due to fluid overload or other factors related to treatment.

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A nurse is planning care for a client who has had a recent cerebrovascular accident (CVA). Which of the following actions should the nurse include in the plan of care to decrease the client's risk for footdrop?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

Correct Answer is ["C","D","E","G"]

Explanation

A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is ["A","B","C","D"]

Explanation

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