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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Related Questions
Correct Answer is A
Explanation
Choice A reason: Skin becomes more vulnerable to sun damage is true because as the skin ages, it loses its elasticity and ability to repair itself from the harmful effects of ultraviolet (UV) radiation. Sun damage can cause wrinkles, age spots, and skin cancer. The nurse would advise the older adult person to protect their skin from the sun by wearing sunscreen, hats, and clothing that covers the skin.
Choice B reason: Sweat gland activity increases is false because as the skin ages, it produces less sweat and oil, which can make the skin dry and prone to itching. The nurse would advise the older adult person to moisturize their skin regularly and avoid hot showers or baths that can dry out the skin.
Choice C reason: Skin becomes darker in unexposed areas is false because as the skin ages, it produces less melanin, the pigment that gives the skin its color. This can make the skin lighter and more sensitive to sunburn. The nurse would advise the older adult person to check their skin for any changes in color, shape, or size of moles or spots that could indicate skin cancer.
Choice D reason: Generous amounts of soap should be used for cleansing is false because as the skin ages, it becomes thinner and more fragile, and can be irritated by harsh chemicals or fragrances. The nurse would advise the older adult person to use mild, unscented soap and water for cleansing, and to pat the skin dry gently.
Correct Answer is A
Explanation
Choice A reason: Can bring about long-term changes in lifestyle is true because persistent pain, also known as chronic pain, is pain that lasts for more than three months or beyond the expected healing time. Persistent pain can affect the physical, psychological, social, and emotional aspects of a person's life, and may require adjustments in daily activities, work, hobbies, relationships, and self-care.
Choice B reason: Is generally gone within 4 months is false because persistent pain does not have a clear end point and may persist for years or even a lifetime. Persistent pain is different from acute pain, which is pain that is sudden, sharp, and usually related to an injury or illness. Acute pain typically lasts for a short time and resolves when the underlying cause is treated.
Choice C reason: Is usually described as a burning pain is false because persistent pain can have various descriptions, depending on the cause, location, and intensity of the pain. Some common words that people use to describe persistent pain are aching, throbbing, stabbing, shooting, tingling, or numbness.
Choice D reason: Leads to significantly altered vital signs is false because persistent pain does not usually cause noticeable changes in vital signs, such as blood pressure, heart rate, respiratory rate, or temperature. This is because the body adapts to persistent pain over time and does not react as strongly as it does to acute pain. However, this does not mean that persistent pain is less severe or less important than acute pain.
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