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
Explanation
The correct answer is A. Increased pain.
Choice A reason: Naloxone is an opioid antagonist that, when administered, reverses the effects of opioids. Since opioids provide analgesia, their reversal will lead to the return of pain sensation. The normal pain response varies widely among individuals and depends on the type and amount of opioid the patient received, as well as their pain threshold and tolerance.
Choice B reason: Somnolence, or drowsiness, is a common effect of opioid administration. Naloxone works by displacing opioids from their receptors, which should counteract the sedative effects of opioids and reduce somnolence. Therefore, after naloxone administration, the nurse should not expect somnolence as a finding.
Choice C reason: Hyperglycemia, or high blood sugar, is not a direct effect of naloxone administration. While some studies suggest that naloxone may affect blood glucose levels under certain conditions, such as in the case of tramadol overdose, it does not typically cause hyperglycemia. Normal blood glucose levels range from 70 to 99 mg/dL fasting, and up to 140 mg/dL two hours after eating.
Choice D reason: Hypoventilation, or reduced breathing rate and depth, is caused by opioid administration. Naloxone’s role is to reverse this effect, restoring normal breathing rates. The normal respiratory rate for a healthy adult at rest is 12 to 20 breaths per minute.
Correct Answer is D
Explanation
The correct answer is D. Contractions.
Choice A Reason: Hypertension Hypertension in pregnancy is a condition that can occur independently of an amniocentesis and is typically monitored throughout the pregnancy. It is characterized by a sustained high blood pressure of 140/90 mmHg or higher. While hypertension is a concern in pregnancy, it is not a direct complication of amniocentesis. Normal ranges for blood pressure in the third trimester are 101.6 to 143.5 mmHg systolic and 62.4 to 94.7 mmHg diastolic.
Choice B Reason: Vomiting Vomiting is not a typical complication following an amniocentesis. It may be associated with other conditions during pregnancy such as hyperemesis gravidarum or gastrointestinal disturbances but is not directly related to the procedure of amniocentesis.
Choice C Reason: Epigastric Pain Epigastric pain is typically associated with conditions like preeclampsia or other gastrointestinal issues in pregnancy, not with amniocentesis. It is characterized by pain in the upper abdomen and is not a common complication post-amniocentesis.
Choice D Reason: Contractions After an amniocentesis, especially at 33 weeks of gestation, monitoring for contractions is crucial because they can indicate preterm labor, which is a known risk associated with the procedure. The normal range for contractions would be none to infrequent Braxton-Hicks contractions, which are not regular and do not signify labor.
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