The rehabilitation nurse determines that the client who has had a hemorrhagic stroke is successfully adapting to functional changes if they:
use adaptive equipment in dressing self.
has difficulty with using modified feeding utensils.
experience bouts of depression and irritability.
get angry with the family if they interrupt a task.
The Correct Answer is A
A. Using adaptive equipment suggests they are finding ways to maintain independence and complete activities of daily living (ADLs) despite any physical or cognitive limitations. This is a positive sign of adaptation.
B. Difficulty using modified feeding utensils suggests that the client is struggling to adapt to the changes caused by the stroke. If they cannot use these utensils effectively, it indicates a challenge in managing their eating independently, which is not a sign of successful adaptation.
C. While emotional responses like depression and irritability are common after a stroke, experiencing these feelings frequently can indicate difficulty in coping with the changes. This does not reflect successful adaptation; rather, it suggests that the client may be struggling emotionally and psychologically with their new circumstances.
D. While frustration can be a normal response to challenges after a stroke, particularly in the context of regaining independence, getting angry at family members may indicate difficulty in coping with the changes or an inability to manage frustration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A calcaneal spur, or heel spur, is a bony growth on the heel bone. This condition is primarily related to foot pain and does not have a direct link to the risk of stroke. It is not relevant in assessing stroke risk.
B. This elevated blood pressure reading indicates hypertension, which is a significant risk factor for both ischemic and hemorrhagic strokes. Chronic high blood pressure can lead to damage of the blood vessels, making them more susceptible to rupture, thus increasing the risk of a hemorrhagic stroke.
C. A glycosylated hemoglobin (HbA1c) level of 5.9% indicates well-managed diabetes, typically within the normal range for most individuals. While uncontrolled diabetes is a risk factor for vascular disease, this level suggests adequate control and does not specifically indicate an increased risk for a hemorrhagic stroke.
D. A recent endoscopy itself does not indicate a direct risk for a hemorrhagic stroke. However, if the endoscopy was performed due to gastrointestinal bleeding or if it resulted in complications, there could be indirect implications, but this option alone does not signify an increased risk for hemorrhagic stroke.
Correct Answer is ["C","D"]
Explanation
A. Using humidifiers can help maintain moisture in the air, which is beneficial if the client is experiencing dry mucous membranes or respiratory discomfort, especially due to chemotherapy. However, while this can be helpful, it’s not the most critical teaching point compared to other options related to infection risk or symptoms monitoring.
B. While engaging in stress-reducing activities is important for overall well-being, gardening may pose specific risks for a client with AML, particularly concerning exposure to soil and potential pathogens. Activities should be carefully considered to avoid any risks of infection or physical strain.
C. Clients with AML, especially those undergoing chemotherapy, have a higher risk of infections due to neutropenia (low white blood cell count). A fever of 100.2°F or higher can be a sign of infection and requires prompt medical evaluation. Thus, this is a crucial point for the client to understand.
D. Fresh vegetables that are not cooked or peeled can harbor bacteria and other pathogens that could pose a risk of infection, especially in immunocompromised patients. Clients undergoing chemotherapy should avoid raw foods that can increase the risk of infections.
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