Marvin is transferred from the ICU to the Tele/Neuro unit 24 hours after receiving tPA. He has left sided hemiplegia with some dysphagia. What nursing interventions should be part of his plan of care? Select all that apply.

Ask the nursing assistant to determine if he can safely sit in a bedside chair.

Passive ROM exercise.

Assess neurologic status.

Coordinate with speech therapy to perform a swallowing evaluation.

Use pillows and positioning devices to maintain proper body alignment.

Pull on his arm to position him on his side.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A reason: Asking the nursing assistant to determine if Marvin can safely sit in a bedside chair is not appropriate. Safety assessments, especially for patients with recent neurological events, should be done by a registered nurse or a physical therapist. This ensures that any nuanced clinical signs indicating instability or risk are recognized and addressed promptly.
Choice B reason: Passive range of motion (ROM) exercises are essential for patients with hemiplegia to prevent complications such as muscle atrophy, joint contractures, and decreased circulation. Regularly performing these exercises can maintain the health of the muscles and joints, promote better blood flow, and help in maintaining some degree of flexibility in the affected limbs.
Choice C reason: Assessing neurologic status is crucial in patients who have had a recent stroke and received tPA treatment. Frequent neurologic assessments help in monitoring for any changes or signs of deterioration. This includes checking consciousness, pupil response, motor function, and sensory perception. Changes in these parameters can indicate complications or the need for immediate medical interventions.
Choice D reason: Coordinating with speech therapy for a swallowing evaluation is essential because Marvin has dysphagia. Swallowing assessments by a speech therapist can determine the patient's ability to swallow safely and the appropriate dietary modifications needed to prevent aspiration, a common risk in patients with dysphagia. This is vital to prevent pneumonia or other respiratory complications.
Choice E reason: Using pillows and positioning devices to maintain proper body alignment is important in preventing complications such as pressure ulcers, muscle contractures, and discomfort. Proper positioning can also assist in maintaining better respiratory function and overall comfort. It also prevents the development of deformities and promotes functional posture, which is especially important for patients with hemiplegia.
Choice F reason: Pulling on his arm to position him on his side is inappropriate and can cause injury, especially in a patient with hemiplegia. This technique can lead to shoulder dislocations or increased pain. Instead, proper repositioning techniques using assistive devices and help from additional staff members should be employed to ensure safe and effective movement of the patient.

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

Explanation

Choice A reason: Unilateral edema is a common sign of DVT. This occurs due to the obstruction of blood flow in the affected vein, leading to fluid buildup in the tissue, which causes swelling. The swelling is usually confined to the area of the leg where the clot is located, making it an important diagnostic indicator. In DVT, the affected limb often appears swollen compared to the other limb, and this can be easily observed by the healthcare provider during the physical examination.

Choice B reason: Nausea is not typically associated with DVT. While nausea can occur due to various medical conditions, it is not a primary symptom of DVT. DVT primarily affects the circulatory system, leading to symptoms related to impaired blood flow, such as swelling, pain, and redness in the affected limb. Therefore, nausea is unlikely to be directly related to the presence of a blood clot in the deep veins of the leg.

Choice C reason: Groin discomfort can be a symptom of DVT, especially if the clot is located in the femoral vein. The femoral vein runs through the groin area, and a clot in this vein can cause pain and tenderness in the groin. This discomfort is due to the pressure and inflammation caused by the clot obstructing blood flow. Patients may report a dull or aching pain in the groin, which can be exacerbated by movement or pressure.

Choice D reason: Calf pain is a classic symptom of DVT. It often presents as cramping, soreness, or aching in the calf due to the presence of a blood clot in the deep veins of the leg. The pain is caused by the increased pressure and inflammation in the affected vein, which irritates the surrounding tissues. This symptom is a key indicator of DVT and should prompt further evaluation and diagnostic testing, such as an ultrasound, to confirm the presence of a clot.

A. Decreasing blood glucose levels B. Increasing serum potassium levels C. Increasing serum sodium levels D. Decreasing serum chloride levels

Correct Answer is C

Explanation

Choice A reason: Decreasing blood glucose levels are not an indicator of effective therapy in patients with acute adrenal insufficiency. In fact, hypoglycemia is a common symptom of Addison's Disease due to insufficient cortisol production, and effective therapy would aim to normalize blood glucose levels, not decrease them further.
Choice B reason: Increasing serum potassium levels would indicate worsening of the condition rather than improvement. Hyperkalemia is a hallmark of Addison's Disease due to aldosterone deficiency, and effective therapy should decrease serum potassium levels, not increase them.
Choice C reason: Increasing serum sodium levels would indicate that the therapy is effective for acute adrenal insufficiency. Addison's Disease is characterized by hyponatremia due to aldosterone deficiency, and effective treatment aims to normalize sodium levels in the blood. An increase in serum sodium levels indicates that the treatment is correcting the underlying electrolyte imbalance.
Choice D reason: Decreasing serum chloride levels are not a specific indicator of effective therapy for Addison's Disease. Chloride levels are generally less affected and not a primary marker for assessing treatment efficacy. The main focus should be on correcting sodium and potassium imbalances.

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Marvin is transferred from the ICU to the Tele/Neuro unit 24 hours after receiving tPA. He has left sided hemiplegia with some dysphagia. What nursing interventions should be part of his plan of care? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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

Explanation

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency (Addison's Disease)?

Correct Answer is C

Explanation

The clinical diagnosis of dementia is based on

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