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 A

Explanation

Choice A reason: Donning appropriate personal protective equipment (PPE) is the most important action to protect the healthcare provider and prevent the spread of the virus while caring for the client.

Choice B reason: Explaining to the client to inform others about potential exposure is important but can be done after ensuring the nurse's safety with proper PPE.

Choice C reason: Teaching the client to wear a mask, hand wash, and social distance is important for preventing the spread of the virus but is not the immediate priority.

Choice D reason: Notifying the charge nurse about the need for assignment to a COVID-19 specified area is necessary for infection control but follows the immediate action of donning PPE.

A. Reason for taking the aspirin. B. Presence of gastric pain. C. Amount of pain control. D. Dosage of ibuprofen taken.

Correct Answer is A

Explanation

Choice A reason: Understanding the reason for taking the aspirin is crucial because aspirin may be prescribed for various reasons, such as pain relief, anti-inflammatory purposes, or cardiovascular protection. Knowing the reason helps the nurse assess if ibuprofen is a suitable substitute or if additional interventions are needed.

Choice B reason: While the presence of gastric pain is important, it is secondary to understanding the underlying reason for aspirin use.

Choice C reason: Assessing the amount of pain control achieved with ibuprofen is important for managing the client's symptoms, but it is not the first priority.

Choice D reason: Knowing the dosage of ibuprofen taken is essential for determining if the client is taking an appropriate amount, but it comes after understanding the initial indication for aspirin use.

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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

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

The nurse is caring for a client who reports running out of aspirin one week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

Correct Answer is A

Explanation

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