A client has been on bed rest following a cerebrovascular accident or stroke that occurred two days ago. On the third day, the plan of care includes getting the client out of bed and into a bedside chair. Prior to assisting the client out of bed for the first time, which action should the nurse take?

Assess the client's brain stem reflexes.

Perform pupillary response assessment.

Assess the client's blood pressure.

Offer the client to void before getting out of bed.

Answer and Explanation

The Correct Answer is C

A.   While assessing brain stem reflexes can provide valuable information about the neurological status of the client, it is not the immediate priority when preparing to move a client from bed to a chair. Brain stem reflexes are more relevant for assessing overall neurological function and response to stimuli, but they do not directly inform the safety and readiness of the client for physical activity.
B.   Assessing the pupillary response is important for evaluating neurological function and consciousness levels. However, it is not directly related to assessing the client’s readiness to be moved from bed to a chair. Pupillary response does not provide specific information about the client’s hemodynamic stability or immediate readiness for physical activity.
C.   Assessing the client’s blood pressure is crucial, especially after a stroke, as the client may be at risk for orthostatic hypotension (a sudden drop in blood pressure when standing up). Checking blood pressure helps ensure that the client is hemodynamically stable and can tolerate the change in position without risking dizziness, fainting, or other complications.
D.   Offering the client the opportunity to void before getting out of bed is a practical measure to ensure comfort and avoid accidents. It helps prevent the need for the client to seek the bathroom immediately after being moved to the chair, which could be disorienting or potentially hazardous.

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Correct Answer is B

Explanation

A. While providing practical advice is useful, this response does not directly address the client's current emotional state or frustration. The immediate need is to support the client emotionally rather than instructing them on dressing techniques. It may also come off as dismissive of the client’s feelings.
B. This response is the most appropriate because it acknowledges and validates the client’s emotional experience. By recognizing their frustration, the nurse shows empathy and understanding, which can help in building a therapeutic relationship. It also opens up a dialogue for the client to express their feelings and concerns, which can improve their overall comfort and cooperation.
C. While education on dressing techniques is beneficial, this response does not address the client's immediate frustration or emotional needs. It also postpones support and could make the client feel like their current struggles are not being adequately addressed in the moment.
D. This response is defensive and does not address the client’s immediate emotional needs. It may escalate the situation by making the client feel like they are being reprimanded for their behavior. It is important to handle such situations with empathy and support rather than focusing on institutional policies.

A. Working together can decrease the risk of back injury to the nurses. B. The technique is intended to maintain straight spinal alignment. C. Turning Instead of pulling reduces the likelihood of skin damage. D. Using two or three people increases client safety.

Correct Answer is B

Explanation

A. While it is true that using proper techniques can reduce the risk of back injuries for healthcare providers, this is not the primary purpose of the log rolling technique. The main goal of log rolling is to protect the client’s spinal alignment rather than focusing on the safety of the staff.
B. This is the best explanation for the purpose of using the log rolling technique. Log rolling is designed to keep the client’s spine in a straight, aligned position while turning. This technique is particularly important for clients with spinal injuries or conditions where maintaining spinal alignment is crucial to prevent further injury or complications.
C. While it is true that turning a client is generally better for skin integrity than pulling, this explanation does not specifically address the purpose of log rolling. Log rolling is more focused on maintaining spinal alignment rather than solely on reducing skin damage.
D. Using two or three people can indeed increase safety during the turning process and help in managing the client more effectively, but this explanation does not capture the primary purpose of the log rolling technique itself.

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Naxlex Comprehensive Predictor Exams

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

Correct Answer is B

Explanation

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?