A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Keep the room brightly lit while providing care.

Minimize verbal interaction with the client.

Monitor for change in speech.

Avoid dropping side rails or abruptly closing the door.

Report any change in level of consciousness.

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Keeping the room brightly lit while providing care may help with orientation but is not a specific instruction related to stroke care.

Choice B reason: Minimizing verbal interaction with the client is not advisable. Communication is essential in assessing the client's neurological status.

Choice C reason: Monitoring for change in speech is important as speech difficulties can indicate a worsening of the stroke or other neurological issues.

Choice D reason: Avoiding dropping side rails or abruptly closing the door helps minimize unnecessary stimulation and agitation, which can be beneficial for a client experiencing a stroke.

Choice E reason: Reporting any change in level of consciousness is critical as it can indicate changes in the client's condition that require immediate medical attention.

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Correct Answer is C

Explanation

Choice A reason: Assisting the client to lie down may increase the risk of aspiration.

Choice B reason: Supplemental liquid feedings may be considered but do not address the immediate issue.

Choice C reason: Demonstrating the tucked-chin position can help reduce the risk of aspiration by ensuring the airway is protected during swallowing.

Choice D reason: Assistive feeding devices may help but do not address the immediate issue of frequent coughing during meals.

A. Observe neck for jugular vein distention. B. Monitor oxygen saturation via continuous pulse oximetry. C. Notify healthcare provider to prepare for pericardiocentesis. D. Assess for paradoxical blood pressure.

Correct Answer is C

Explanation

Choice A reason: Observing for jugular vein distention is important but not the immediate intervention.

Choice B reason: Monitoring oxygen saturation is necessary but secondary to preparing for pericardiocentesis.

Choice C reason: Pericardiocentesis is the definitive treatment for cardiac tamponade, and notifying the healthcare provider to prepare for this procedure is the most important intervention.

Choice D reason: Assessing for paradoxical blood pressure helps confirm cardiac tamponade but does not address the immediate need for treatment.

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A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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