A nurse is preparing to discharge a client who had a cerebrovascular accident and has left-sided weakness. The client is having difficulty completing ADLs. Which of the following is the priority action by the nurse?

Recommend occupational therapy referral for the client.

Reinforce teaching about the client's prescribed medications.

Provide the client with a list of community resources.

Encourage the client to discuss nutritional needs with a dietitian.

Answer and Explanation

The Correct Answer is A

A) Recommend occupational therapy referral for the client: This is the priority action because the client is experiencing difficulty with activities of daily living (ADLs) due to left-sided weakness following a cerebrovascular accident. Occupational therapy focuses on improving the client's ability to perform ADLs and regain independence. Referring the client to occupational therapy is essential for maximizing functional ability and promoting recovery.

B) Reinforce teaching about the client's prescribed medications: While medication education is important for overall health management, it is not the priority in this situation. The client's immediate need is assistance with ADLs to address functional deficits resulting from the cerebrovascular accident.

C) Provide the client with a list of community resources: Community resources may be beneficial for the client's long-term care and support, but addressing the immediate need for assistance with ADLs takes precedence. Referring the client to occupational therapy will address the functional limitations more directly and effectively.

D) Encourage the client to discuss nutritional needs with a dietitian: Nutritional needs are important for overall health and recovery, but addressing the client's physical limitations and ADLs is the priority at this time. Once the client's ability to perform ADLs improves, discussions about nutrition can follow as part of a comprehensive care plan.

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Correct Answer is C

Explanation

A) Administer prescribed insulin:

Administering insulin is an essential aspect of managing type 1 diabetes mellitus, but before administering insulin, it's crucial to assess the client's current blood glucose level to determine the appropriate insulin dosage. Administering insulin without knowing the client's blood glucose level could lead to hypoglycemia if the blood glucose level is already low.

B) Check the calibration of the glucometer:

While it's important to ensure that the glucometer is calibrated correctly for accurate blood glucose readings, this step can be performed after obtaining the client's blood glucose level. Checking the calibration of the glucometer does not directly address the immediate need to assess the client's blood glucose level.

C) Obtain the client's capillary blood glucose level:

This is the most appropriate action to take first when providing morning care to a client with type 1 diabetes mellitus. Assessing the client's blood glucose level allows the nurse to determine the client's current glycemic status and make informed decisions about subsequent care, including insulin administration and breakfast provision.

D) Provide the client's breakfast:

Providing breakfast is an important aspect of morning care for a client with diabetes, but it should be done after assessing the client's blood glucose level. Depending on the client's blood glucose level, the nurse may need to adjust the timing or composition of the breakfast to ensure optimal glycemic control.

A. Notify the nurse manager. B. Check the family member's vital signs. C. Obtain the family member's health history. D. Complete an incident report.

Correct Answer is B

Explanation

A) Notify the nurse manager:

While it's essential to involve the nurse manager in situations involving unexpected events or emergencies, the immediate priority is to assess the well-being of the fainting family member. Notifying the nurse manager can be done after ensuring the family member's immediate needs are addressed.

B) Check the family member's vital signs:

The first action the nurse should take is to assess the fainting family member's vital signs to determine their current physiological status. Checking vital signs can provide crucial information about the person's condition and guide further actions. This assessment helps ensure the family member's safety and well-being.

C) Obtain the family member's health history:

Obtaining the family member's health history is important for understanding any underlying medical conditions that may have contributed to the fainting episode. However, assessing vital signs takes precedence to address any immediate medical concerns related to the fainting episode.

D) Complete an incident report:

Completing an incident report is necessary to document the fainting episode for organizational records and quality improvement purposes. However, this task can be completed after addressing the immediate needs of the fainting family member and ensuring their safety.

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A nurse is preparing to discharge a client who had a cerebrovascular accident and has left-sided weakness. The client is having difficulty completing ADLs. Which of the following is the priority action by the nurse?

Nursing Test Bank

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