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 A

Explanation

A) Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B) Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C) Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D) Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.

A. Repeat information to the client. B. Write information on a whiteboard. C. Talk loudly into the affected ear. D. Speak directly facing the client. E. None F. None

Correct Answer is D

Explanation

The correct answer is Choice D

Choice A rationale: Repeating information may reinforce understanding but does not address the core barrier in unilateral hearing loss, which is sound localization and clarity. Auditory input from one ear limits binaural processing, making it harder to distinguish speech from background noise. Repetition without visual cues or proper orientation may still result in misinterpretation. Effective communication requires compensating for the sensory deficit, not merely reiterating content. Thus, repetition alone is insufficient for optimal education delivery.

Choice B rationale: Writing on a whiteboard provides visual support but lacks the dynamic interaction necessary for patient education. While visual aids help reinforce concepts, they do not allow for immediate clarification or emotional engagement. Pain management education involves nuanced discussion of pharmacologic options, side effects, and patient preferences. Relying solely on written communication may hinder comprehension, especially if literacy or cognitive load is a concern. It should supplement, not replace, direct verbal and visual interaction.

Choice C rationale: Speaking loudly into the affected ear is counterproductive and may distort sound further. In unilateral hearing loss, the affected ear has reduced or absent auditory function, and increasing volume does not restore clarity. Loud speech can also be perceived as aggressive or uncomfortable. Effective communication requires engaging the functional ear and using visual cues to enhance comprehension. Loudness does not compensate for neural deficits in auditory processing and may worsen patient experience.

Choice D rationale: Facing the client allows for optimal use of visual cues such as lip reading, facial expressions, and gestures, which are critical in compensating for unilateral auditory deficits. This technique engages the functional ear while supporting multimodal communication. It respects the neurophysiological limitations of monaural hearing and enhances speech perception through visual-auditory integration. Direct face-to-face interaction also fosters trust and allows for immediate feedback, making it the most scientifically sound approach for patient education.

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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

Correct Answer is A

Explanation

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

Correct Answer is D

Explanation

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