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","B","D"]

Explanation

Choice A reason: The sedimentation rate (ESR) is a common test used to detect inflammation associated with conditions such as rheumatoid arthritis. An elevated ESR indicates the presence of inflammation in the body.

Choice B reason: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis and are useful in confirming the diagnosis. The presence of these antibodies can help distinguish RA from other inflammatory conditions.

Choice C reason: D-Dimer is primarily used to rule out thrombotic conditions such as deep vein thrombosis and pulmonary embolism. It is not specifically related to the diagnosis or management of rheumatoid arthritis.

Choice D reason: C-reactive protein (CRP) is another marker of inflammation that is often elevated in rheumatoid arthritis. It provides information about the level of inflammation and can be used to monitor disease activity and response to treatment.

Choice E reason: While a white blood cell count can provide general information about infection or inflammation, it is not specific to rheumatoid arthritis and is not as useful as the other tests mentioned for diagnosing or managing RA.

A. Severe motor dysfunction determines the extent of successful habilitation. B. Continued development of the brain lesion determines the child's outcome. C. Brain damage with CP is not progressive but does have a variable course. D. CP is one of the most common permanent physical disabilities in children.

Correct Answer is C

Explanation

Choice A reason: Severe motor dysfunction does influence the extent of successful habilitation, but it does not fully answer the mother’s concern regarding the progression of CP. The focus should be on reassuring the mother about the non-progressive nature of CP.

Choice B reason: The development of the brain lesion is already established in CP and does not continue to develop; thus, it does not determine the child's future outcome. The brain lesion's presence from birth does not change over time.

Choice C reason: Brain damage associated with CP is non-progressive, meaning it does not worsen over time. However, the symptoms and functional impairments can vary and fluctuate, which might make it seem as though the condition is changing.

Choice D reason: While it’s true that CP is one of the most common permanent physical disabilities in children, it doesn’t provide specific information about the progression of the disease. The mother needs to understand that the brain damage itself is not progressive.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D"]

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Correct Answer is C

Explanation

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