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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Demonstrating commitment to the special needs of the geriatric client by means of board-certification is the primary purpose of geriatric nursing certifications, as it shows that the nurse has met the standards of knowledge, skills, and practice in the field of gerontology. Board-certification also indicates that the nurse is dedicated to providing quality care and improving outcomes for the older adult population.

Choice B reason: Raising the level of professionalism for the geriatric facility is not the primary purpose of geriatric nursing certifications, as it is a secondary benefit that may result from having certified nurses on staff. Professionalism is not only determined by the credentials of the nurses, but also by their attitudes, behaviors, and values.

Choice C reason: Assuring the basic competency of the geriatric nurse is not the primary purpose of geriatric nursing certifications, as it is a minimum requirement that should be met by all nurses who work with older adults. Competency is not only measured by passing an exam, but also by demonstrating clinical judgment, ethical decision-making, and lifelong learning.

Choice D reason: Addressing the current shortage of specialized geriatric nurses is not the primary purpose of geriatric nursing certifications, as it is a challenge that cannot be solved by certifications alone. The shortage of geriatric nurses is influenced by many factors, such as the aging population, the lack of interest and incentives, and the high turnover and burnout rates.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the primary purpose of geriatric nursing certifications.

A. Measure the blood pressure in sitting and standing positions. B. Measure the blood pressure in the left arm. C. Document the findings in the medical record; elevated blood pressures are normal in older adults. D. Immediately contact the medical provider. E. None of the above.

Correct Answer is B

Explanation

Choice A reason: Measure the blood pressure in sitting and standing positions is not the next action by the nurse, as it is not relevant to the situation. The nurse should compare the blood pressure readings from both arms, not from different postures.

Choice B reason: Measure the blood pressure in the left arm is the next action by the nurse, as it can help determine if the high blood pressure is consistent or isolated to one arm. A difference of more than 10 mm Hg between the arms may indicate a vascular problem, such as atherosclerosis, aneurysm, or coarctation of the aorta.

Choice C reason: Document the findings in the medical record; elevated blood pressures are normal in older adults is not the next action by the nurse, as it is inaccurate and irresponsible. The nurse should not assume that elevated blood pressures are normal in older adults, as they may indicate hypertension, which is a risk factor for cardiovascular disease, stroke, and kidney damage. The nurse should also not document the findings without further assessment and intervention.

Choice D reason: Immediately contact the medical provider is not the next action by the nurse, as it may be premature and unnecessary. The nurse should first confirm the accuracy of the blood pressure readings by measuring the blood pressure in the left arm and checking the calibration of the device. The nurse should also consider other factors that may affect the blood pressure, such as pain, stress, caffeine, or medication.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the next action by the nurse.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the primary purpose of geriatric nursing certifications?

Correct Answer is A

Explanation

A nurse measures an older adult's blood pressure on the right arm and notes a reading of 150/100. The nurse waits 5 minutes and measures the blood pressure again in the right arm and obtains a reading of 152/100. What is the next action by the nurse?

Correct Answer is B

Explanation

An older adult client had hip replacement surgery 1 day ago, and the nurse thinks that the client is also demonstrating dementia. Which client assessment does the nurse use to determine whether this client is experiencing pain?

For a cognitively impaired patient who cannot accurately report pain, which assessment tool would be most useful?

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