The practical nurse (PN) is assisting the nurse (RN) during the admission of a client with a possible cerebrovascular accident (CVA). Which action(s) should the PN complete in the assessment phase of the admitting process? Select all that apply.
Record automatic blood pressure readings.
Develop the initial plan of care.
Initiate range of motion exercises.
Gather information about the client's symptoms.
Observe for muscle weakness and fatigue.
Correct Answer : A,D,E
A. Record automatic blood pressure readings: Measuring and recording vital signs is part of the assessment phase.
B. Develop the initial plan of care: This is part of the planning phase, not assessment.
C. Initiate range of motion exercises: This is part of implementation, not assessment.
D. Gather information about the client's symptoms: Collecting subjective data is part of assessment.
E. Observe for muscle weakness and fatigue: Gathering objective data by observation is part of assessment.
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Related Questions
Correct Answer is C
Explanation
A. Report the incident and the UAP for further action by the nurse-manager:
Reporting may be needed later, but immediate intervention is required to stop inappropriate behavior.
B. Tell both of them to lower their voices in consideration of other residents:
This addresses the noise but not the unprofessional and potentially abusive behavior.
C. Enter the room and tell the UAP to leave the room immediately:
Immediate action is necessary to protect the resident from verbal abuse and to de-escalate the situation.
D. Tell the resident and the UAP that shouting is not permitted:
This fails to remove the UAP from the situation and address potential abuse concerns.
Correct Answer is D
Explanation
A. Use of pain medication:
Helps understand management but not primary for history-taking of inflammation.
B. Pattern of inflammation:
More relevant for tracking progress than initial history.
C. Mechanism of injury:
Important if trauma is suspected, but the case describes persistent symptoms.
D. Duration of pain:
Key for determining chronicity and possible underlying cause.
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