The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation?

Provide support on the unaffected side.

Hook an arm under the client's left arm.

Use a gait belt standing on affected side.

Hold the gait belt with palms facing down.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Provide support on the unaffected side: Supporting from the unaffected side gives less control if the weak side gives out. Assistance should be on the affected side to better prevent falls and provide stabilization.

B. Hook an arm under the client's left arm: This is unsafe and risks injury to both the client and nurse. It provides poor leverage, may dislocate the shoulder, and does not allow controlled support during ambulation.

C. Use a gait belt standing on affected side: This is the safest technique. Standing on the affected side offers direct support and balance while the gait belt allows secure, ergonomic assistance during movement.

D. Hold the gait belt with palms facing down: Gait belts should be held with palms facing up, which provides a more secure grip and better control if the client loses balance during ambulation.

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Correct Answer is ["21"]

Explanation

Calculation:

Convert the total volume from liters (L) to milliliters (mL).

Total volume = 1 L × 1000 mL/L

= 1000 mL.

Convert the infusion time from hours to minutes.

Infusion time = 12 hours × 60 min/hour

= 720 minutes.

Drop factor of the IV administration set = 15 gtt/mL.

Calculate the flow rate in drops per minute (gtt/min).

Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)

= (1000 mL × 15 gtt/mL) / 720 min

= 15000 / 720 gtt/min

= 20.833... gtt/min.

Round the answer to the nearest whole number.

= 21 gtt/min.

A. Consider having the teen's caregiver wait in the clinic reception area. B. Encourage the adolescent to handle the physical exam instruments. C. Allow time for talking before beginning the physical assessment. D. Familiarize the adolescent with the clinic setting and healthcare staff. E. Make every effort to establish eye contact with the adolescent.

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

Explanation

Rationale:
A. Consider having the teen's caregiver wait in the clinic reception area: Adolescents with ASD may experience heightened anxiety in unfamiliar environments. Having their caregiver nearby can offer a sense of security and comfort, making the experience less overwhelming.

B. Encourage the adolescent to handle the physical exam instruments: Allowing the adolescent to touch and explore the equipment before use helps reduce sensory-related anxiety. It also increases cooperation by promoting a sense of predictability and control.

C. Allow time for talking before beginning the physical assessment: Taking time to communicate and build rapport before initiating the assessment helps reduce anxiety and fosters trust. Many adolescents with ASD need more time to process information and adjust to new interactions.

D. Familiarize the adolescent with the clinic setting and healthcare staff: Gradual exposure to the physical space and people helps reduce sensory overload and builds comfort with the environment. Structured familiarity can prevent overstimulation and improve cooperation.

E. Make every effort to establish eye contact with the adolescent: Insisting on eye contact can increase distress, as many individuals with ASD find direct eye contact uncomfortable or overwhelming. Respecting their communication style is more effective than imposing neurotypical expectations.

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The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["21"]

Explanation

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

Explanation

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