A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?
Request crutches from a medical equipment provider.
Advise the client to install grab bars in the bathroom at home.
Encourage the client to allow a home care aide to perform ADLS for them.
Contact hospice to provide follow-up care for the client.
The Correct Answer is B
Choice A rationale:
Request crutches from a medical equipment provider. This choice is not appropriate for a client with left-sided weakness due to a stroke. Crutches are primarily used for lower extremity support and would not address the client's mobility and safety needs related to their left-sided weakness.
Choice B rationale:
Advise the client to install grab bars in the bathroom at home. This is the correct choice. Installing grab bars in the bathroom will enhance the client's safety and independence. Left-sided weakness can result in balance issues, and having grab bars near the toilet and in the shower can help prevent falls and provide the client with support while using these facilities. This intervention promotes the client's functional autonomy and reduces the risk of injury.
Choice C rationale:
Encourage the client to allow a home care aide to perform ADLs for them. While it might be necessary for a client with severe disability to receive assistance with Activities of Daily Living (ADLs), the question does not provide enough information to suggest that the client's condition warrants this level of intervention. Encouraging independence is generally preferred to maintain the client's self-esteem and engagement in daily life activities.
Choice D rationale:
Contact hospice to provide follow-up care for the client. Hospice care is intended for clients with terminal illnesses who are in the final stages of life. A client who has had a stroke and is experiencing left-sided weakness does not automatically qualify for hospice care. The client's condition can be managed with rehabilitation and support, and hospice care is not appropriate in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.
Choice A rationale:
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
Choice B rationale:
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
Choice C rationale:
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
Choice D rationale:
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.
Correct Answer is D
Explanation
Choice A rationale:
The National League for Nursing (NLN) focuses on nursing education standards and resources for nursing faculty. While it could provide useful insights, it's not the primary resource for policy creation related to procedures like catheter insertion.
Choice B rationale:
The American Academy of Nursing (AAN) is a professional organization that promotes leadership and education within nursing. While it might offer recommendations, it's not the primary resource for policy related to procedural changes in clinical settings.
Choice C rationale:
The Agency for Healthcare Research and Quality (AHRQ) is involved in research and quality improvement initiatives in healthcare. While it could provide evidence-based practices, it's not the primary source for policies specific to nursing procedures.
Choice D rationale:
The State Nurse Practice Act (NPA) outlines the scope of nursing practice within a particular state. It governs what nurses are allowed to do, including procedures like catheter insertion. The NPA ensures that nursing actions are within legal and regulatory bounds, making it the most relevant resource for creating a policy about catheter insertion.
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