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?

"This unit has a policy against staff harassment."

"It is important to dress the right arm first."

"Dressing must be a frustrating experience for you."

"We will give you a class on dressing tomorrow."

Monitor the client's white blood cell count.

Answer and Explanation

The Correct Answer is C

A. "This unit has a policy against staff harassment."

This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.

B. "It is important to dress the right arm first."

This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.

C. "Dressing must be a frustrating experience for you."

This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.

D. "We will give you a class on dressing tomorrow."

This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.

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Correct Answer is C

Explanation

A. Initiate a fall risk protocol for the client:

Initiating a fall risk protocol may be premature based solely on observations of an upright posture and a smooth, steady gait. While falls are a significant concern in older adults, these observations suggest that the client currently exhibits good balance and mobility, which may not warrant immediate initiation of a fall risk protocol. Fall risk assessments typically involve a comprehensive evaluation of multiple factors beyond posture and gait, such as medical history, medications, cognitive status, and environmental factors.

B. Teach the client to shorten the stride to prevent falls:

Teaching the client to shorten their stride to prevent falls may not be necessary based on the observed smooth and steady gait. Shortening the stride is often recommended for individuals who exhibit signs of imbalance or instability during walking. However, in this scenario, the client demonstrates a smooth and steady gait, suggesting that their current gait pattern is effective and does not pose an immediate risk of falling.

C. Determine the client's activity tolerance:

Assessing the client's activity tolerance is an appropriate next step in the nursing process. While the observed upright posture and smooth, steady gait are positive indicators of mobility, understanding the client's overall activity tolerance provides valuable insight into their functional capacity and ability to perform activities of daily living safely. This assessment helps tailor care interventions to meet the client's individual needs and promotes optimal independence and quality of life.

D. Record the client's ability to perform ADLs safely:

Documenting the client's ability to perform activities of daily living (ADLs) safely is an essential component of nursing assessment and documentation. However, it may not be the most immediate action to take following the observation of an upright posture and smooth, steady gait. While documenting findings is important for maintaining accurate records and facilitating communication among healthcare team members, further assessment of the client's activity tolerance would provide additional context for documenting their functional status accurately.

A. Provide a numeric pain scale. B. Observe body language and movement. C. Ask the client to describe the pain. D. Identify effective pain relief measures.

Correct Answer is C

Explanation

A. Provide a numeric pain scale:

While a numeric pain scale can help quantify the intensity of pain, it does not directly assess the quality or characteristics of the pain, which is important for identifying potential causes and selecting appropriate interventions.

B. Observe body language and movement:

Observing body language and movement can provide valuable information about the client's pain experience, but it primarily assesses the behavior associated with pain rather than the quality or characteristics of the pain itself.

C. Ask the client to describe the pain:

This approach allows the client to provide subjective information about the pain, including its quality, location, intensity, duration, and aggravating or alleviating factors. Asking the client to describe the pain helps the nurse gain insight into its characteristics, which can aid in identifying the underlying cause and determining appropriate interventions.

D. Identify effective pain relief measures:

Identifying effective pain relief measures is important for managing the client's pain, but it does not directly assess the quality or characteristics of the pain. Before implementing pain relief measures, it's essential to understand the nature of the pain through client self-report or other assessment methods.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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