A nurse is caring for a client who had a stroke.
Complete the following sentence using the lists of options.
The client is at risk for developing
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.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. Stroking the lower abdomen. This technique is not a recognized method for stimulating urination.
B. Performing Kegel exercises prior to urination. Kegel exercises strengthen pelvic muscles but do not directly promote urination.
C. Pouring warm water over the perineum. Warm water can stimulate sensory nerves and promote relaxation of the urethral sphincter, helping to initiate urination.
D. Leaning backward when sitting and attempting to urinate. The proper posture for urination is sitting upright or leaning slightly forward, not backward.
Correct Answer is A
Explanation
A. "The client's room number and diagnosis are written on the hallway communication board." This is a breach of client confidentiality because it publicly displays protected health information (PHI) where unauthorized individuals, including visitors and non-essential staff, could see it. This violates HIPAA (Health Insurance Portability and Accountability Act) regulations.
B. "The history and physical in the electronic medical record describes the client's previous suicide attempt." The electronic medical record (EMR) is a secure and appropriate place for documenting the client's health history. Access is restricted to healthcare providers involved in the client’s care.
C. "The time when the client can next have pain medication is written on their bedside communication board." This does not violate confidentiality, as it is relevant to the client’s direct care and is visible only to the healthcare team and the client.
D. "The client is wearing a color-coded bracelet that states they are a fall risk." Color-coded bracelets are a standard safety practice in hospitals to communicate important patient care needs to staff. This does not disclose specific medical information beyond the fall risk status.
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