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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I am at lower risk for developing cervical warts." This is an incorrect statement because the Gardasil vaccine does not protect against genital warts caused by HPV types other than types 6 and 11. The vaccine protects against HPV types 16 and 18, which cause most cases of cervical cancer.
B: This option is incomplete and does not provide any information for the nurse to determine if further teaching is needed.
C: This statement is correct and indicates that the client understands the purpose of the Gardasil vaccine.
D: This statement is incorrect because the Gardasil vaccine does not prevent HPV infection from occurring.
Correct Answer is B
Explanation
The assessment finding that is most important in determining which client has a higher risk for testicular cancer is cryptorchidism as an infant. Cryptorchidism, or undescended testicle(s), is a condition where one or both testicles fail to move from the abdomen into the scrotum before birth. Males with cryptorchidism are many times more likely to get testicular cancer than those with normally descended testicles. Cryptorchidism is the main risk factor for testicular cancer, while other factors such as previous STI, low sperm count, and family history of cancer are less clear or less common
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