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 B

Explanation

Choice A reason: This method is not appropriate because it can cause physical and psychological harm to the client. It can injure the client's mouth, trigger a gag reflex, or cause choking. It can also make the client feel violated, frightened, or angry. This can worsen the client's behavior and damage the trust between the client and the caregiver.

Choice B reason: This method is appropriate because it can help the client maintain their dignity, autonomy, and sense of control. It can also stimulate the client's cognitive and motor skills, and encourage the client to participate in their own care. This can improve the client's mood and behavior, and foster a positive relationship between the client and the caregiver.

Choice C reason: This method is not appropriate because it can cause emotional and psychological harm to the client. It can make the client feel disrespected, humiliated, or threatened. It can also increase the client's anxiety, agitation, or resistance. This can worsen the client's behavior and damage the trust between the client and the caregiver.

Choice D reason: This method is not appropriate because it can cause physical and psychological harm to the client. It can injure the client's mouth, trigger a gag reflex, or cause choking. It can also make the client feel ignored, neglected, or devalued. This can worsen the client's behavior and damage the trust between the client and the caregiver.

A. Older adult's self-report B. FPSR C. Pain medication frequency D. Older adult's pain diary

Correct Answer is D

Explanation

Choice A reason: Older adult's self-report is a subjective measure of pain that may not reflect the actual intensity or quality of pain. It may also be influenced by factors such as cognitive impairment, mood, or cultural norms.

Choice B reason: FPSR stands for Face, Pain Scale-Revised, which is a tool to assess pain in infants and children who cannot verbalize their pain. It is not suitable for older adults, who may have different facial expressions or reactions to pain.

Choice C reason: Pain medication frequency is an indirect measure of pain that may not capture the effectiveness or side effects of pharmacotherapy. It may also vary depending on the type, dose, and route of administration of pain medication.

Choice D reason: Older adult's pain diary is a comprehensive and reliable measure of pain that can track the changes in pain level, quality, and location over time. It can also record the impact of pain on daily activities, mood, sleep, and quality of life. It can help the nurse to evaluate the outcomes of comfort measures and pharmacotherapy, and to adjust the pain management plan accordingly.

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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

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