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.

Answer and Explanation

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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Correct Answer is {"dropdown-group-1":"B"}

Explanation

The term for severe itching is "pruritus," so the nurse should document the client's complaint as such. Pruritus can be caused by a variety of factors, including allergic reactions, skin conditions, and liver or kidney disease.

The nurse should assess the client's skin for any visible signs of irritation or rash and ask about any recent changes in medications or diet. Treatment for pruritus will depend on the underlying cause but may include topical or oral medications, cool compresses, or avoiding irritants.

A. Cardiac and respiratory status. B. Circulation, movement, and sensation. C. ROM status. D. Renal and hepatic function.

Correct Answer is B

Explanation

Before and after applying a cast, it is essential to assess the client's circulation, movement, and sensation to ensure there is no damage to the nerves or blood vessels. Assessing cardiac and respiratory status is not as relevant to cast application. ROM status is important but can be assessed by assessing movement and sensation. Renal and hepatic function are not directly related to cast application.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the clinic with complaints of severe itching. The nurse documents this as: dropdown

Correct Answer is {"dropdown-group-1":"B"}

Explanation

The nurse is caring for a client who has had a fracture reduction using a cast. Which of the following would be most important for the nurse to assess before and after the cast application?

Correct Answer is B

Explanation

Which of the following interventions would be appropriate for a client who has undergone surgery for a liver disorder and has started shivering?

A client on a prescribed medication for a skin disorder visits the clinic complaining of a skin rash. Which of the following would explain the client's condition?

The client is undergoing a tuning fork test to assess for hearing conduction. The nurse performs a Rinne test. How will this test be performed?

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The nurse is assessing a 2-year-old client who has sustained a fracture from falling off a slide while playing in the park. What type of fracture did the child most likely sustain?

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A nurse is reviewing the history along with physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom?

A client, who is recovering from bariatric surgery, is returning from the post-anesthesia care unit. Which nursing assessment is of greatest concern in the immediate postoperative period for this client?