A nurse is preparing to discharge a client who had a cerebrovascular accident and has left-sided weakness. The client is having difficulty completing ADLs. Which of the following is the priority action by the nurse?
Recommend occupational therapy referral for the client.
Reinforce teaching about the client's prescribed medications.
Provide the client with a list of community resources.
Encourage the client to discuss nutritional needs with a dietitian.
The Correct Answer is A
A) Recommend occupational therapy referral for the client: This is the priority action because the client is experiencing difficulty with activities of daily living (ADLs) due to left-sided weakness following a cerebrovascular accident. Occupational therapy focuses on improving the client's ability to perform ADLs and regain independence. Referring the client to occupational therapy is essential for maximizing functional ability and promoting recovery.
B) Reinforce teaching about the client's prescribed medications: While medication education is important for overall health management, it is not the priority in this situation. The client's immediate need is assistance with ADLs to address functional deficits resulting from the cerebrovascular accident.
C) Provide the client with a list of community resources: Community resources may be beneficial for the client's long-term care and support, but addressing the immediate need for assistance with ADLs takes precedence. Referring the client to occupational therapy will address the functional limitations more directly and effectively.
D) Encourage the client to discuss nutritional needs with a dietitian: Nutritional needs are important for overall health and recovery, but addressing the client's physical limitations and ADLs is the priority at this time. Once the client's ability to perform ADLs improves, discussions about nutrition can follow as part of a comprehensive care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B) Log the previous user out of the system:
The immediate action the nurse should take is to protect the client's confidentiality by logging out the previous user from the computer system. This ensures that unauthorized individuals do not have access to the client's health information. By taking this step promptly, the nurse mitigates the risk of unauthorized viewing of sensitive information.
A) Complete an incident report:
While completing an incident report is important for documenting the occurrence, it is not the first action the nurse should take. The priority is to address the immediate breach of confidentiality by securing the computer system to prevent further unauthorized access.
C) Report the incident to the charge nurse:
Reporting the incident to the charge nurse is essential, but it should follow the immediate action of logging out the previous user from the system. The charge nurse can then coordinate any necessary follow-up actions and ensure that appropriate measures are taken to prevent similar incidents in the future.
D) Offer to conduct a unit in-service on client confidentiality:
While staff education on client confidentiality is valuable for preventing future breaches, it is not the first action needed in response to the immediate situation. Addressing the current breach takes precedence to protect the client's privacy. Staff education can be considered as a proactive measure after addressing the immediate concern.
Correct Answer is D
Explanation
A) Turn off electrical equipment in the client's room: While turning off electrical equipment can help prevent the spread of fire if the source is electrical, it may not be the most immediate action to take after removing the client from the room. The priority is to activate the alarm to alert others and initiate the fire response protocol.
B) Use a Class A fire extinguisher to contain the fire: Using a fire extinguisher is a potential action, but the type of fire extinguisher needed depends on the type of fire. Class A fire extinguishers are suitable for ordinary combustibles such as wood and paper. However, since the source of the fire is a trash can, the fire may involve combustible materials beyond Class A. Therefore, activating the alarm takes precedence over extinguishing the fire.
C) Close the door to the client's room: Closing the door can help contain the fire and prevent its spread to other areas. While this action is important, it is secondary to activating the alarm, which alerts others to the fire and initiates the response process.
D) Activate the alarm outside the client's room: This is the most appropriate action to take first. Activating the alarm alerts others to the fire, enabling them to respond promptly and effectively. It initiates the facility's fire response protocol, including evacuating occupants and summoning the fire department. This action ensures the safety of everyone in the vicinity and allows for a coordinated emergency response.
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