An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Place a bedside commode next to bed.

Measure neurological vital signs every 4 hours.

Suction oral cavity every 4 hours.

Encourage family to participate in the client's care.

Play classical music in room while client is

Answer and Explanation

Correct Answer : A,B,D

The correct answer is a. Place a bedside commode next to bed., b. Measure neurological vital signs every 4 hours., d. Encourage family to participate in the client’s care.

Choice A rationale:

Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.

Choice B rationale:

Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.

Choice C rationale:

Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management. Routine suctioning can also cause discomfort and potential injury.

Choice D rationale:

Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process. Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.

Choice E rationale:

Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation. The effectiveness of music therapy can vary based on individual preferences.

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Correct Answer is B

Explanation

A) Incorrect - While discussing the potential for asymptomatic partners is important, addressing the client's concerns and providing accurate information is more immediate.
B) Correct- Syphilis and other STIs are important public health concerns. The nurse should provide accurate information, answer questions, and correct any misconceptions the client might have. This approach supports the client's knowledge and understanding of their health condition and prevents the spread of misinformation.
C) Incorrect - While discussing contraceptives is relevant to sexual health education, it may not directly address the client's concerns about their prior infections.
D) Incorrect - Notifying local health departments is important for reporting communicable diseases, but it doesn't directly address the client's current situation and concerns.

A. Inspect skin for redness. B. Use a residual limb shrinker. C. Avoid range of motion exercises. D. Apply alcohol to the residual limb after bathing.

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

Explanation

The correct answer is a. Inspect skin for redness and b. Use a residual limb shrinker.

Choice A rationale:

Inspecting the skin for redness is crucial to identify any signs of infection or pressure sores early. Redness can indicate irritation or the beginning of a pressure ulcer, which needs to be addressed promptly to prevent further complications.

Choice B rationale:

Using a residual limb shrinker helps to reduce swelling and shape the residual limb for prosthetic fitting. It also helps in managing pain and promoting healing by providing consistent compression.

Choice C rationale:

Avoiding range of motion exercises is incorrect. Range of motion exercises are essential to maintain joint flexibility and prevent contractures, which can hinder the use of a prosthetic limb.

Choice D rationale:

Applying alcohol to the residual limb after bathing is not recommended. Alcohol can dry out the skin and cause irritation, which can lead to skin breakdown and infection. Instead, the residual limb should be kept clean and moisturized with appropriate skin care products.

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An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Correct Answer is B

Explanation

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

Explanation

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