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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is **a. Observe for bruising of the skin.**

Choice A rationale: Observing for bruising of the skin is an appropriate nursing intervention when caring for a client receiving alteplase (recombinant tissue plasminogen activator or rt-PA), a thrombolytic medication used to dissolve blood clots. Alteplase can increase the risk of bleeding, including bruising, as it works to break down the clot. Closely monitoring the client for any signs of bleeding or bruising is crucial to identify and manage potential complications.

Choice B rationale: Administering medications intramuscularly is not recommended when a client is receiving alteplase. Intramuscular injections can increase the risk of bleeding and should be avoided, as alteplase can impair the body's ability to form clots and stop bleeding.

Choice C rationale: Monitoring vital signs every 4 hours is not the appropriate frequency for a client receiving alteplase. Vital signs should be monitored more frequently, typically every 30 minutes to 1 hour, to closely observe for any changes that may indicate bleeding or other complications.

Choice D rationale: Providing a diet low in protein is not a necessary intervention for a client receiving alteplase. Alteplase works by targeting the blood clot and does not require specific dietary modifications. The focus should be on monitoring for bleeding and managing any potential complications, rather than adjusting the client's diet.

A. Place the oxygen tank away from curtains or drapes. B. Ensure that the client checks the gauge weekly. C. Store the oxygen tank wrench in a locked cabinet. D. Have the client store smaller tanks under his bed.

Correct Answer is A

Explanation

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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?

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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?