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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Correct Answer is C

Explanation

A. Weak quadriceps muscles can occur with electrolyte imbalances, but the provided values do not indicate hypokalemia or other issues causing muscle weakness.
B. Decreased deep tendon reflexes are generally associated with elevated calcium levels or other electrolyte disturbances but are not specifically indicated by the given lab values.
C. A calcium level of 4.5 mg/dL is significantly low (normal range is typically around 8.5-10.5 mg/dL), which can lead to hypocalcemia symptoms such as tingling of the extremities and tetany due to increased neuromuscular excitability.
D. Light-headedness when standing up (orthostatic hypotension) is more related to fluid volume status or dehydration rather than directly related to the given electrolyte levels.

A. Explain the importance of maintaining morning hygiene practices. B. Tell the patient that daily morning baths are the "normal" routine. C. Cancel hygiene for the day and attempt again in the morning. D. Defer the bath until evening and pass on the information to the next shift.

Correct Answer is D

Explanation

A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.

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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

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

Correct Answer is C

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Correct Answer is D

Explanation

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