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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
cryptorchidism as an infant. Cryptorchidism, or undescended testicles, is a known risk factor for testicular cancer. During fetal development, the testicles form in the abdomen and descend into the scrotum before birth. Failure of one or both testicles to descend into the scrotum can increase the risk of testicular cancer later in life. Therefore, a history of cryptorchidism as an infant is the most important assessment finding to identify clients at higher risk of developing testicular cancer.
Choice A, previous sexually transmitted infection (STI), is incorrect because although STIs can increase the risk of certain types of cancer, they are not a significant risk factor for testicular cancer.
Choice C, low sperm count, is incorrect because although low sperm count can be associated with testicular cancer, it is not a reliable indicator for determining a higher risk for testicular cancer. Low sperm count may also be caused by various other factors, such as hormonal imbalances, infections, varicocele, and genetic abnormalities. While it is important to monitor and treat low sperm count, it is not a definitive indicator of testicular cancer risk.
Correct Answer is D
Explanation
Diarrhea. A client who is recovering from bariatric surgery and is eating from a portable commode is at risk for diarrhea. Diarrhea can cause fluid and electrolyte imbalances, leading to dehydration, which can be life-threatening, especially in the immediate postoperative period.
Option A, impaired mobility, would not be a priority concern in the immediate postoperative period for this client.
Option B, impaired gas exchange, is not related to the situation.
Option C, self-care deficit, maybe a concern but is not as significant as diarrhea in the immediate postoperative period.
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