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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This is a significant finding that warrants immediate notification. Changes in mental status in elderly patients can indicate a variety of issues, including infection (such as a urinary tract infection), dehydration, or other acute illnesses. Given that elderly patients are at higher risk for delirium and other cognitive changes, this finding should be taken seriously.
B. These vital signs are largely within normal limits for an elderly patient. While the blood pressure is on the higher side, the heart rate and respiratory rate are within acceptable ranges. Therefore, this does not warrant immediate notification unless other symptoms are present.
C. This statement is reassuring and suggests that the client is not experiencing complications related to the indwelling catheter, such as infection or obstruction. It does not indicate any need for immediate notification of the provider.
D. Cloudy urine with sediment can be indicative of a urinary tract infection (UTI) or other complications related to the indwelling catheter. While this finding is concerning and may require further evaluation, it is not as urgent as a change in mental status. It should still be reported to the healthcare provider but may not necessitate immediate action.

A. drinking a glass of red wine with dinner. B. infection with human papilloma virus (HPV). C. having a PAP test performed annually by her gynecologist. D. being married for 21 years to the same person.

Correct Answer is B

Explanation

A. This statement is false in terms of being a major risk factor for cervical cancer. While excessive alcohol consumption may have various health implications, moderate drinking, such as a glass of red wine with dinner, is not directly linked to an increased risk of cervical cancer.

B. Infection with certain high-risk strains of HPV is a major risk factor for cervical cancer. HPV is a sexually transmitted virus that can cause changes in cervical cells, leading to dysplasia and potentially progressing to cancer if not monitored and treated.
C. In fact, regular Pap tests are a preventive measure that can help detect cervical changes early before they develop into cancer. They are not a risk factor but rather a protective factor against the progression of cervical dysplasia to cancer.
D. While sexual history can influence HPV transmission, simply being married to the same person for an extended period does not inherently increase the risk of cervical cancer.

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The rehabilitation nurse determines that the client who has had a hemorrhagic stroke is successfully adapting to functional changes if they:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an elderly female client who has an indwelling catheter. Which data in the assessment warrants notification of the health care provider?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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