The nurse is planning care for a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?
Provide instruction on blood-thinning medication.
Assess the client for the ability to ambulate independently.
Include the client in planning care and setting goals.
Praise the client when using adaptive equipment.
The Correct Answer is B
Assess the client for the ability to ambulate independently. The highest priority nursing intervention for a client admitted to a neurologic rehabilitation unit following a cerebrovascular accident is to assess the client's ability to ambulate independently. This assessment will help the nurse determine the level of assistance required and develop an appropriate care plan.
Option A. Providing instruction on blood-thinning medication is not the highest priority as it can be done later when the client's ambulation status is stable.
Option C. Including the client in the planning of care and setting of goals is important but not the highest priority in this situation as it can be done after assessing the client's ambulation status.
Option D. Praise the client when using adaptive equipment, is not the highest priority as the client's ambulation status is more important at this point.
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Related Questions
Correct Answer is D
Explanation
Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.
Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.
Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.
Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.
Correct Answer is A
Explanation
Exposing the affected area to air. To maintain skin integrity, the nurse should advise the client to expose the affected area to air.
Barrier garments, such as liners and protective pants, can trap moisture and irritate the skin, which can lead to skin breakdown. Exposing the affected area to air can help keep the skin dry and prevent skin breakdown.
B is not the correct answer because the application of moisture sealant can help protect the skin and prevent skin breakdown.
C is not the correct answer because using an electric room deodorizer is not related to maintaining skin integrity.
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