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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is b. Social services.

Choice A: Occupational therapy - This is incorrect because occupational therapy focuses on improving daily living and working skills, not providing wheelchairs.

Choice B: Social services - This is the correct answer. Discharge planning begins at admission and should prepare for the functional ability of the client. This includes whether they have caregivers at home, or if they’re in need of one. A referral for social services can be made as needed to address gaps in the clients support system or resources.

Choice C: Home health - This is incorrect because home health provides medical treatment, not equipment like wheelchairs.

Choice D: Physical therapy - This is incorrect because physical therapy helps improve mobility and strength, but does not provide wheelchairs.

A. "The client who had abdominal surgery 3 days ago is reporting feeling constipated.” B. "The client who had the hip replacement reports pain as 4 on a scale of 0 to 10.” C. "The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.” D. "The client who is scheduled for discharge today states they are ready to sign their paperwork.”

Correct Answer is C

Explanation

Choice A rationale:

The client who had abdominal surgery 3 days ago reporting feeling constipated is an important assessment, but an inability to void after indwelling urinary catheter removal takes precedence due to the risk of urinary retention and potential complications such as bladder distention.

Choice B rationale:

The client who had a hip replacement reporting pain as 4 on a scale of 0 to 10 requires assessment and intervention, but an inability to void is a higher priority concern due to the potential impact on renal function and the urinary system.

Choice C rationale:

The client who had an indwelling urinary catheter removed 8 hours ago reporting an inability to void is the correct choice. This situation raises concerns about urinary retention, which can lead to serious complications such as bladder distention, urinary tract infections, and potential damage to the urinary system.

Choice D rationale:

The client scheduled for discharge today expressing readiness to sign paperwork is not an urgent concern compared to the other options. While discharge planning is important, addressing potential physiological issues takes precedence over administrative tasks.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?

Correct Answer is B

Explanation

A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?

Correct Answer is C

Explanation

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