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

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

A. Set target dates for completion. B. Identify areas of support. C. Determine goals and objectives. D. Implement recommended strategies.

Correct Answer is C

Explanation

Choice A rationale:

Setting target dates for completion is an important step, but it should come after goals and objectives have been established. Goals and objectives provide the foundation for developing a timeline and action plan.

Choice B rationale:

Identifying areas of support is valuable, but it's not the next immediate action after developing the initial plan. Before seeking support, the nurse should clarify the goals and objectives to ensure that the support is aligned with the intended outcomes.

Choice C rationale:

Determining goals and objectives is the next logical step after developing the initial plan. Goals and objectives help guide the committee's work and ensure that the policy revisions are purposeful and aligned with the desired outcomes.

Choice D rationale:

Implementing recommended strategies is a subsequent action that follows the establishment of goals and objectives. Without clear goals and objectives, the strategies might lack direction and cohesiveness.

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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?

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Correct Answer is C

Explanation

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