Following a cerebrovascular accident (CVA), a client's prescriptions include neurologic assessments every 8 hours, and bedrest. The agency assessment tool includes evaluation of the client's posture. Which action should the nurse implement?

Assist the client to stand at the bedside long enough to observe posture.

Observe the client's ability to sit upright or unassisted while in the bed.

Document that posture could not be evaluated due to prescribed bedrest.

Ask the client to describe normal posture while walking and standing.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Assist the client to stand at the bedside long enough to observe posture: Assisting the client to stand would violate the bedrest order, which is in place to prevent complications such as increased intracranial pressure or falls following a CVA. Standing could pose unnecessary risks and is not appropriate when safer alternatives are available.

B. Observe the client's ability to sit upright or unassisted while in the bed: Evaluating posture can still be done safely within the constraints of bedrest by assessing how well the client can maintain an upright seated position. This allows the nurse to assess muscle tone, balance, and neurological function without compromising safety.

C. Document that posture could not be evaluated due to prescribed bedrest: Bedrest limits standing or walking, but it does not prevent all forms of posture evaluation. The nurse still has a responsibility to assess posture in ways that align with safety protocols and should not omit this part of the neurological assessment.

D. Ask the client to describe normal posture while walking and standing: Relying on the client's verbal report does not replace direct observation. Objective assessment is necessary for accurate neurological evaluation, especially in post-CVA clients where deficits in muscle control and balance may not be fully recognized by the client.

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

Explanation

Rationale:
A. Reach under a gown to listen and take care that no clothing rubs on the stethoscope: Direct placement of the stethoscope on the skin prevents interference from clothing, which can cause extraneous "roaring" or scratching sounds. Ensuring no fabric rubs against the stethoscope helps obtain clearer, more reliable auscultation results.

B. Keep the examination room warm, and warm the stethoscope: A cold environment or cold stethoscope can trigger shivering in the client, leading to muscle movement noises during auscultation. Warming the room and stethoscope minimizes these artifacts and allows better evaluation of breath sounds without false interference.

C. Wet the chest hair before auscultating: Chest hair can create crackling or static sounds when it rubs against the stethoscope. Lightly wetting the hair reduces friction, ensuring that abnormal lung sounds like crackles are genuine findings and not artifacts caused by the hair movement.

D. Ensure the room is as quiet as possible: Background noise can make auscultation findings harder to hear and interpret. A quiet environment helps the nurse distinguish actual breath sounds from ambient noise, especially important when assessing for subtle abnormalities like crackles or decreased breath sounds.

E. Document the roaring and crackles: Documenting artifact sounds like roaring without first addressing the source could lead to incorrect clinical conclusions. Roaring caused by hair or clothing interference must be corrected before recording findings, so immediate documentation without artifact correction is not appropriate.

A. Amount and type of caffeinated drinks before bedtime. B. Usual bed time and time of awakenings. C. History of seasonal allergies and nasal congestion. D. Urinary frequency and episodes of nocturia.

Correct Answer is B

Explanation

Rationale:
A. Amount and type of caffeinated drinks before bedtime: Caffeine intake can definitely impact sleep quality, but assessing specific contributors like caffeine is a secondary step. First, the nurse must gather broader information about overall sleep habits to identify where disturbances occur.

B. Usual bed time and time of awakenings: Establishing the client’s typical sleep and wake times is the foundation for evaluating a sleep pattern disturbance. It helps determine whether the issue lies with sleep onset, maintenance, early awakening, or overall duration, guiding the development of a targeted and effective care plan.

C. History of seasonal allergies and nasal congestion: Allergies and congestion can disrupt sleep by causing breathing difficulties, but they are secondary considerations. These should be explored after first understanding the client's general sleep routine and identifying primary sleep concerns.

D. Urinary frequency and episodes of nocturia: Nocturia can significantly disrupt sleep, especially in older adults. However, like other specific contributors, it should be assessed after the overall sleep pattern is reviewed to ensure a comprehensive understanding of the client's sleep issues.

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Following a cerebrovascular accident (CVA), a client's prescriptions include neurologic assessments every 8 hours, and bedrest. The agency assessment tool includes evaluation of the client's posture. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

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

Explanation

The nurse assesses a client with a sleep pattern disturbance. While developing a plan of care (POC), which assessment data should the nurse obtain first?

Correct Answer is B

Explanation

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow up assessment should the nurse complete?

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

An older adult client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

Exhibits Drag from Word Choices to complete the sentence. Heart sounds are loudest for S1 at the dropdown. And for S2 at the dropdown