The practical nurse (PN) is providing care for a client with a history of a stroke and who has aphasia. The client is exhibiting restlessness, shallow respirations and is clenching teeth. Which problem should the PN assess further?
Alteration in comfort.
Deficit in diversional activity.
Elevated blood pressure.
Change in blood glucose level.
The Correct Answer is A
A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Total volume to be infused: 250 mL of tube feeding.
To be infused over 8 hours.
Calculate the infusion rate in mL per hour.
Infusion rate (mL/hour) = Total volume (mL) / Total infusion time (hours)
= 250 mL / 8 hours
= 31.25
Round to the nearest whole number: 31.
Correct Answer is B
Explanation
A. Standards of practice for practical nursing: While important for general nursing care, national or professional standards do not replace the specific legal requirements outlined by the state’s licensing authority, which directly govern what a PN can and cannot do.
B. The licensing state's PN scope of practice: Each state defines the legal scope of practice for practical nurses, including what tasks they are authorized to perform. Reviewing the specific state's scope of practice ensures the PN practices legally and professionally in the new employment setting.
C. Geriatric standards of care guidelines: Geriatric care guidelines help provide quality care for older adults but are not the first priority when ensuring lawful nursing practice across state lines. Legal requirements must be understood first.
D. The employing agency's procedure manuals: While agency policies are important for specific job performance, they must be aligned with the state's legal scope of practice. Knowing the legal boundaries first is crucial before following any workplace procedures.
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