A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Raise the side rails on both sides of the client’s bed during repositioning.

Reposition the client without the use of assistive devices.

Discuss the client’s preferences for determining a repositioning schedule.

Evaluate the client’s ability to help with repositioning.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Evaluate the client’s ability to help with repositioning.

This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort.

The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.

Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.

The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.

Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.

The nurse should use assistive devices that are appropriate for the client’s condition and weight.

Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.

The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.

The nurse should also involve the client in the care plan and respect their preferences whenever possible.

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Correct Answer is C

Explanation

The correct answer is choice C, frequent swallowing.

This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.

Choice A is wrong because elevated pain level is not a specific sign of hemorrhage.

Pain is expected after a tonsillectomy and can be managed with medication and fluids.

Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage.

Drowsiness can be caused by anesthesia, medication, or dehydration.

Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage.

Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.

Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.

Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults.

Normal ranges for plasma clotting variables depend on the specific test and method used.

A. Determine previous coping skills used by the client. B. Facilitate the client's problem-solving skillls C. Assist the client in expressing alternative behaviours. D. Establish the responsibilities of the nurse and client

Correct Answer is D

Explanation

Choice A reason:

Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.

Choice B reason:

Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.

Choice Creason:

Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.

Choice D reason:

The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

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A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is C

Explanation

A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Correct Answer is D

Explanation

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

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