The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

Encourage the patient to perform as many self-care activities as possible.

Place the patient on bed rest to prevent fatigue.

Coordinate with occupational therapy for gait training.

Provide a complete bed bath to promote patient comfort.

Answer and Explanation

The Correct Answer is A

A. Encouraging self-care helps promote independence and functional recovery in stroke patients, supporting rehabilitation and enhancing self-esteem.
B. Bed rest is not recommended as it can contribute to muscle deconditioning and complications associated with immobility.
C. While coordination with therapy is beneficial, gait training is typically handled by physical therapy rather than occupational therapy.
D. Providing a complete bed bath limits the patient’s autonomy; encouraging partial participation supports the patient's involvement in self-care.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This outcome is specific, measurable, and directly addresses the goal of managing constipation by aiming for a bowel movement.
B. Discontinuing pain medication abruptly may be unrealistic and can cause distress for the patient.
C. Ambulation may help with constipation but does not directly measure or ensure bowel movement.
D. Offering laxatives or stool softeners is an intervention rather than a measurable patient outcome.

A. Elevated blood pressure B. Increased pulse rate C. Cyanosis D. Restlessness

Correct Answer is C

Explanation

A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.

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The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Correct Answer is A

Explanation

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?

Correct Answer is C

Explanation

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