A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
Evaluate the client's ability to help with repositioning
Reposition the client without the use of assistive devices.
Raise the side rails on both sides of the client's bed during repositioning
Discuss the client's preferences for determining a repositioning schedule
The Correct Answer is A
Rationale:
A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.
B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.
C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.
D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Stridor: Stridor is a high-pitched airway sound typically associated with hypocalcemia due to laryngeal spasms from increased neuromuscular excitability. It is not a common feature of hypercalcemia, where muscle excitability is decreased.
B. Seizure: Seizures result from heightened neuronal activity, which occurs more frequently in hypocalcemia. Hypercalcemia depresses neural and muscular activity, making seizures an unlikely symptom.
C. Elevated hematocrit: Elevated hematocrit can occur with dehydration but is not a direct effect of high serum calcium levels. It is not considered a hallmark manifestation of hypercalcemia.
D. Personality change: Hypercalcemia affects the central nervous system, often leading to confusion, lethargy, or personality changes. These alterations occur due to the depressive effects of excess calcium on brain function.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Rationale:
- Minimize environmental stimuli for the client: The client is displaying signs of acute mania including hyperactivity, distractibility, pressured speech, and hallucinations. A low-stimulation environment helps reduce sensory overload, agitation, and impulsive behavior, promoting safety and stabilization in manic patients.
- Weigh the client each day: The client has poor nutritional intake and increased activity, increasing risk for weight loss. Daily weights allow nurses to monitor nutritional status and detect early signs of dehydration or malnutrition, which are common in manic episodes where the client neglects eating.
- Provide the client with high-calorie fluids every hour: Due to constant movement, poor oral intake, and elevated energy levels, clients in a manic state are at high risk for fluid and calorie deficits. Offering high-calorie fluids frequently supports hydration and nutrition without requiring the client to sit down for full meals, which they may be too distracted to do.
- Encourage the client to avoid napping during the day: This client has not slept for 2 days, which exacerbates mania and disorientation. Preventing napping would worsen sleep deprivation. Instead, the nurse should promote rest whenever possible to help regulate mood, decrease agitation, and improve cognition in manic clients.
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