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 A
Explanation
A) Includes quotes from the client:
Including direct quotes from the client in documentation provides accurate information about the client's statements or expressions. This practice enhances the clarity and validity of the documentation, as it captures the client's own words, which may be important for conveying their thoughts, feelings, or symptoms.
B) Remains logged in to the charting system throughout the shift:
Remaining logged in to the charting system throughout the shift poses a security risk and violates principles of confidentiality. Nurses should log out of the system when not actively using it to prevent unauthorized access to sensitive patient information.
C) Makes reference in the nurse's notes of completing an incident report:
While documenting the completion of an incident report is important for communication and quality improvement purposes, referencing it directly in the nurse's notes may not be appropriate. Incident reports are typically separate documents used for reporting adverse events or incidents, and their contents may not be part of the client's medical record.
D) Documents that the provider wrote an inaccurate prescription:
Documenting that the provider wrote an inaccurate prescription is not within the scope of a nurse's documentation responsibilities. If a nurse identifies an inaccurate prescription, the appropriate action is to clarify the prescription with the provider through established communication channels rather than documenting the error in the client's chart.
Correct Answer is ["B","C","D"]
Explanation
"Gather enough supplies to last for 2 weeks": This information is essential for disaster preparedness. During emergencies, such as natural disasters or pandemics, access to resources may be limited for an extended period. Having a sufficient supply of food, water, medications, and other essentials for at least two weeks ensures that older adults can sustain themselves until assistance becomes available.
C) "Have a backup supply of nonprescription medications": It is crucial for older adults to have a backup supply of nonprescription medications, such as pain relievers, antacids, or allergy medications, in case they are unable to access pharmacies during a disaster. Having these medications readily available can help manage common health issues that may arise during emergencies.
D) "Stock 2 liters of water per person per day": Adequate hydration is essential for maintaining health, especially during emergencies when access to clean water may be disrupted. Older adults are particularly vulnerable to dehydration, so having a sufficient supply of water—approximately 2 liters per person per day—for drinking, cooking, and hygiene purposes is critical for their well-being.
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