The nurse in a rehabilitation center is caring for a client diagnosed with new-onset stroke with right-side hemiparesis. Which intervention should the nurse implement when caring for this client?
Raises all four side rails.
Orders a two-person assist with a transfer.
Gives the client a dry erase board.
May need to incorporate repetition.
None of the above.
The Correct Answer is C
Choice A reason: Raises all four side rails is not the best intervention, as it may not prevent the client from falling and may increase the risk of injury and entrapment. Raising all four side rails may also be considered a form of restraint, which should be avoided unless absolutely necessary.
Choice B reason: Orders a two-person assist with a transfer is not the best intervention, as it may not be appropriate for the client's level of mobility and may reduce the client's independence and self-esteem. The nurse should assess the client's ability to transfer and use the appropriate assistive device and number of staff to ensure safety and comfort.
Choice C reason: Gives the client a dry erase board is the best intervention, as it can facilitate the client's communication and expression of needs and preferences. The client may have difficulty speaking or writing due to the stroke, which can affect the language and motor areas of the brain. A dry erase board can allow the client to use simple words, symbols, or drawings to convey their messages.
Choice D reason: May need to incorporate repetition is not the best intervention, as it is not specific and may not be effective for the client's learning and retention. The nurse should use individualized and evidence-based strategies to teach the client and their family about the stroke, its effects, and the rehabilitation plan. Repetition may be one of the strategies, but not the only one.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the best intervention for the nurse to implement when caring for this client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: 2400 mL/day is the recommended fluid intake for older adults, according to the National Council on Aging. This amount can help prevent dehydration, which can cause various health problems in older adults, such as urinary tract infections, constipation, confusion, and falls.
Choice B reason: 1920 mL/day is not enough fluid intake for older adults, as it is below the minimum requirement of 6-8 glasses of fluid a day, according to Age UK. This amount can increase the risk of dehydration and its complications in older adults.
Choice C reason: 3000 mL/day is too much fluid intake for older adults, as it exceeds the maximum limit of 10 glasses of fluid a day, according to The Conversation. This amount can cause overhydration, which can lead to hyponatremia, a condition where the sodium level in the blood becomes too low. Hyponatremia can cause symptoms such as nausea, headache, confusion, and seizures.
Choice D reason: 1500 mL/day is not enough fluid intake for older adults, as it is half of the recommended amount of 2400 mL/day, according to the National Council on Aging. This amount can increase the risk of dehydration and its complications in older adults.
Correct Answer is D
Explanation
Choice A reason: Position the client to achieve their comfort is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Comfort is important, but not the priority in this situation.
Choice B reason: Offer toileting and a sip of water is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Toileting and hydration are important, but not the priority in this situation.
Choice C reason: Place side rails up x 4 is not the most important intervention, as it may not prevent the client from getting out of bed and falling. Side rails may also be considered a restraint, which can increase the risk of injury and agitation. Side rails are not a substitute for proper supervision and assistance.
Choice D reason: Instruct the client to ask for help before getting up is the most important intervention, as it can prevent the client from falling and injuring themselves. Opioid analgesics can impair the client's balance, coordination, and judgment, making them more prone to falls. The nurse should educate the client about the effects of opioids and the importance of asking for help before attempting to get out of bed.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the most important intervention for the nurse to implement before leaving the client’s room.
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