An older adult comes to the emergency department after falling at home, and reports "I can't walk without losing my balance." Which steps should the nurse implement for this client?
Organize the reperfusion recombinant tissue plasminogen activator (tPA) infusion.
Determine symptom onset or when the fall occurred.
Arrange for a transfer immediately to the radiology department.
Perform a comprehensive neurologic assessment.
None of the above.
The Correct Answer is D
Choice A reason: Organize the reperfusion recombinant tissue plasminogen activator (tPA) infusion is not the appropriate step, as it is a treatment for acute ischemic stroke, which has not been confirmed in this client. tPA is a clot-busting drug that can restore blood flow to the brain, but it has strict criteria and time window for its use. The nurse should not assume that the client has a stroke without further assessment and diagnosis.
Choice B reason: Determine symptom onset or when the fall occurred is not the appropriate step, as it is not the priority for this client. The nurse should first assess the client's vital signs, neurologic status, and potential injuries from the fall. The symptom onset or fall time may be relevant for the diagnosis and treatment of the underlying cause, but it is not the most urgent information to obtain.
Choice C reason: Arrange for a transfer immediately to the radiology department is not the appropriate step, as it is not the most immediate intervention for this client. The nurse should first stabilize the client's condition, perform a thorough assessment, and obtain orders from the medical provider. The radiology department may be needed for diagnostic tests, such as computed tomography (CT) scan or magnetic resonance imaging (MRI), but it is not the first destination for this client.
Choice D reason: Perform a comprehensive neurologic assessment is the appropriate step, as it can help identify the possible cause of the client's balance problem and rule out a stroke or other serious condition. A neurologic assessment includes checking the client's level of consciousness, orientation, speech, cranial nerve function, motor strength, sensory perception, coordination, and reflexes. The nurse should also monitor the client's vital signs, oxygen saturation, and blood glucose levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Can bring about long-term changes in lifestyle is true because persistent pain, also known as chronic pain, is pain that lasts for more than three months or beyond the expected healing time. Persistent pain can affect the physical, psychological, social, and emotional aspects of a person's life, and may require adjustments in daily activities, work, hobbies, relationships, and self-care.
Choice B reason: Is generally gone within 4 months is false because persistent pain does not have a clear end point and may persist for years or even a lifetime. Persistent pain is different from acute pain, which is pain that is sudden, sharp, and usually related to an injury or illness. Acute pain typically lasts for a short time and resolves when the underlying cause is treated.
Choice C reason: Is usually described as a burning pain is false because persistent pain can have various descriptions, depending on the cause, location, and intensity of the pain. Some common words that people use to describe persistent pain are aching, throbbing, stabbing, shooting, tingling, or numbness.
Choice D reason: Leads to significantly altered vital signs is false because persistent pain does not usually cause noticeable changes in vital signs, such as blood pressure, heart rate, respiratory rate, or temperature. This is because the body adapts to persistent pain over time and does not react as strongly as it does to acute pain. However, this does not mean that persistent pain is less severe or less important than acute pain.
Correct Answer is D
Explanation
Choice A reason: Set walking distance goals is not the best goal, as it is too specific and may not be appropriate for all older clients with diabetes. Walking distance may vary depending on the client's physical condition, comorbidities, and preferences.
Choice B reason: Stabilize the serum glucose is not the best goal, as it is too vague and does not reflect the client's involvement in their care. Serum glucose levels may fluctuate depending on various factors, such as diet, medication, stress, and infection.
Choice C reason: Plan for consistent exercise is not the best goal, as it is not comprehensive and does not address other aspects of diabetes management, such as nutrition, medication, and monitoring. Exercise is only one component of a holistic care plan for older clients with diabetes.
Choice D reason: Facilitate self-management is the best goal, as it encompasses all the elements of diabetes care and empowers the client to take charge of their health. Self-management involves educating the client about diabetes, providing support and resources, and encouraging adherence to the prescribed treatment regimen.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the best goal for planning nursing care for an older client with diabetes mellitus.
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