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. Protamine: Protamine is used to reverse the effects of heparin, particularly in cases of heparin overdose or to stop excessive bleeding. It does not treat allergic reactions like urticaria.
B. Naloxone: Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression or overdose. It has no effect on histamine-mediated symptoms such as urticaria.
C. Hydralazine: Hydralazine is an antihypertensive medication that lowers blood pressure by relaxing arterial smooth muscle. It is not appropriate for managing allergic skin reactions.
D. Diphenhydramine: Diphenhydramine is an antihistamine that blocks histamine receptors, making it effective for treating allergic reactions such as urticaria (hives). It reduces itching, swelling, and redness caused by histamine release.
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.
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