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A nurse is caring for a client who had a stroke.

Exhibits

Complete the following sentence using the lists of options.

The client is at risk for developing 

due to their
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

The client is at risk for developing deep vein thrombosis (DVT) due to their immobility.

Rationale:

  • Swelling and tenderness in the calf are key signs of DVT, which is a common complication of immobility after a stroke.

  • Immobility leads to venous stasis, increasing the risk of clot formation.


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Related Questions

Correct Answer is C

Explanation

A. "A client was placed in the waiting room based on their triage assessment." Hospitals can prioritize clients based on triage assessment as long as they receive a medical screening examination and stabilizing treatment if necessary.
B. "A client was transferred to the inpatient antepartum unit to rule out preterm labor." EMTALA requires that hospitals evaluate and stabilize clients with emergency medical conditions, including preterm labor. Transferring a client within the same facility for further evaluation does not violate EMTALA.
C. "A client was referred to the county hospital for medical screening evaluation." Under EMTALA, hospitals must provide a medical screening examination and necessary stabilizing treatment before referring or transferring a client, regardless of their insurance status. Sending a client elsewhere for evaluation without treatment is a violation.
D. "A stable client was transferred to a public hospital that provides reduced-cost care." Once a client has been stabilized, hospitals may arrange for transfer to another facility, provided the transfer meets EMTALA guidelines and is in the client's best interest.

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

The key pieces of information that indicate the client is at risk for falls include:

  1. Admitted following a fall down approximately five steps – Indicates a recent fall history.
  2. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two – Suggests potential confusion or altered mental status.
  3. Client has a history of falls and orthostatic hypotension per client's partner – A significant risk factor for future falls.
  4. Client uses a walker – Indicates mobility impairment.
  5. Client ordered new glasses following an eye exam last week but has not received them yet – Vision impairment increases fall risk.
  6. Blood pressure: Lying: 130/90 mm Hg, Sitting: 128/88 mm Hg, Standing: 98/60 mm Hg – Orthostatic hypotension (drop in BP upon standing) can cause dizziness and falls.

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