A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke.
Which of the following information is the priority for the nurse to discuss?
Choosing an agency to provide home physical therapy.
Obtaining an alert system to get help in case of a fall.
Providing information about available transportation resources.
Reviewing information about support groups for individuals who have had a stroke.
The Correct Answer is B
Choice A rationale:
Choosing an agency to provide home physical therapy is important, but it is not the priority in this situation. The client's safety and immediate needs should be addressed first.
Choice B rationale:
Obtaining an alert system to get help in case of a fall is the priority for an older adult living alone with left-sided weakness following a stroke. Falls can result in serious injuries, so having an alert system ensures the client can call for assistance promptly, enhancing their safety and well-being.
Choice C rationale:
Providing information about available transportation resources is important for the client's long-term independence and quality of life. However, immediate safety concerns, such as the risk of falls, should be addressed first.
Choice D rationale:
Reviewing information about support groups for individuals who have had a stroke is essential for the client's emotional well-being and social support. However, immediate safety measures, such as fall prevention, take precedence in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Applying a pressure dressing at the IV site might be necessary after removing the catheter, but it does not address the inflammation and discomfort caused by phlebitis. Warm, moist compresses are more appropriate for this situation.
Choice B rationale:
Placing a warm, moist compress on the site is the correct action for phlebitis. Heat helps improve blood circulation, reduce inflammation, and provide relief from pain and discomfort. This choice addresses the client's condition effectively.
Choice C rationale:
Expressing drainage from the IV site and sending it for culture is not necessary in this context. Phlebitis is primarily an inflammatory condition, and drainage culture is not a standard practice for phlebitis.
Choice D rationale:
Inserting a new IV catheter distal to the discontinued IV site is not the immediate action to take for phlebitis. First, the nurse should address the inflammation and pain with warm compresses. If a new IV site is needed, it can be considered after managing the client's symptoms.
Correct Answer is A
Explanation
Choice A rationale:
Encouraging fluid intake of 2,500 mL/day is the correct choice for a client with a fever due to an infection. Adequate hydration is essential in managing fever as it helps to prevent dehydration, maintain electrolyte balance, and support the body's immune response. Increasing fluid intake, preferably water, can also aid in lowering body temperature and promoting overall comfort.
Choice B rationale:
Maintaining the environmental temperature at 16°C to 18°C (60°F to 65°F) is not an appropriate intervention for a client with a fever. While it's essential to keep the client comfortable, adjusting the room temperature within a specific range is not the primary intervention. Focus should be on managing the fever through hydration, antipyretic medications, and addressing the underlying infection.
Choice C rationale:
Immersing the client in cold water is not a recommended intervention for managing fever. Cold water immersion can lead to shock, vasoconstriction, and potentially worsen the condition. It is essential to use methods like tepid sponging or cooling blankets if necessary, but these interventions should be performed under healthcare provider guidance and monitoring.
Choice D rationale:
Assisting the client to ambulate is a general nursing care activity and does not specifically address the fever due to infection. While ambulation is encouraged for many patients to prevent complications related to immobility, it is not the primary intervention for managing fever. The focus should be on hydration and other appropriate measures to reduce fever.
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