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 ["A","B","E"]
Explanation
Choice A rationale:
Depression commonly coexists with eating disorders. Patients with eating disorders often experience profound sadness, hopelessness, and a distorted body image, leading to depressive symptoms. Addressing both conditions simultaneously is crucial for effective treatment.
Choice B rationale:
Obsessive-compulsive disorder (OCD) frequently accompanies eating disorders. Obsessive thoughts about body weight, shape, and food intake are common in individuals with eating disorders. These obsessions can lead to compulsive behaviors, such as strict dietary rules or excessive exercise, reinforcing the connection between eating disorders and OCD.
Choice C rationale:
Schizophrenia is not typically considered a comorbidity of eating disorders. Schizophrenia involves distorted thinking, hallucinations, and impaired emotional responses, which are distinct from the symptoms of eating disorders. While it's essential to assess patients comprehensively, schizophrenia is not a common comorbidity of eating disorders.
Choice D rationale:
Breathing-related sleep disorder is not a direct comorbidity of eating disorders. However, individuals with severe eating disorders, especially anorexia nervosa, may experience complications like sleep apnea due to extreme weight loss. While this is a potential issue, it is not a direct comorbidity of eating disorders for all patients.
Choice E rationale:
Anxiety often coexists with eating disorders. Anxiety about body weight, shape, and food intake is a significant concern for individuals with eating disorders. This anxiety can further perpetuate disordered eating behaviors, creating a cycle that is challenging to break without addressing the underlying anxiety.
Correct Answer is C
Explanation
The correct answer is choice C: Initiate continuous cardiac monitoring.
Choice A rationale:
Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by severe dehydration due to osmotic diuresis, and fluid replacement is a critical component of treatment to restore hydration and circulatory volume.
Choice B rationale:
Monitoring vital signs every 8 hours is not sufficient for a child with DKA. DKA is an acute, life-threatening condition that requires close monitoring of vital signs to detect changes in the patient’s condition promptly. Vital signs should be monitored more frequently, typically every 1 to 2 hours, depending on the severity of the DKA and institutional protocols.
Choice C rationale:
Continuous cardiac monitoring is recommended for a child with DKA. DKA can lead to serious electrolyte imbalances, such as hypokalemia, which can cause cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these potential complications.
Choice D rationale:
Administering subcutaneous insulin 30 minutes before meals is not appropriate for the acute management of DKA. In DKA, insulin is typically administered intravenously to rapidly decrease blood glucose levels and correct metabolic acidosis. Subcutaneous insulin is not used until the patient is stable and able to eat.
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