A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?

Choice A reason: The client's financial resources is not the most important factor for the nurse to consider. Although Meals-on-Wheels is a low-cost or free service that provides nutritious meals to homebound seniors and people with disabilities, it does not require a specific income level or financial status to qualify. The nurse should focus on the client's nutritional and functional needs, rather than their economic situation.

Choice B reason: The client's level of family support is not the most important factor for the nurse to consider. Although having family members who can assist with meal preparation and delivery can be helpful and beneficial for the client, it is not a requirement or a guarantee for receiving Meals-on-Wheels. The nurse should assess the client's individual capabilities and preferences, rather than their family availability or involvement.

Choice C reason: The client's access to transportation is not the most important factor for the nurse to consider. Although having access to transportation can enable the client to obtain food and groceries from other sources, such as stores, markets, or restaurants, it is not a criterion or a barrier for receiving Meals-on-Wheels. The nurse should evaluate the client's dietary and health needs, rather than their mobility or transportation options.

Choice D reason: The client's ability to prepare meals is the most important factor for the nurse to consider. Meals-on-Wheels is designed to serve clients who are unable to cook or shop for themselves due to physical, mental, or social limitations. The nurse should determine if the client has any impairments or challenges that prevent them from preparing their own meals, such as vision loss, arthritis, dementia, or isolation. If the client has difficulty or inability to prepare meals, they may be eligible for Meals-on-Wheels.

Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.

Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skin care, and comfort measures to the client.

Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.

Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.