A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
Evaluate the client's ability to help with repositioning
Reposition the client without the use of assistive devices.
Raise the side rails on both sides of the client's bed during repositioning
Discuss the client's preferences for determining a repositioning schedule
The Correct Answer is A
Rationale:
A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.
B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.
C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.
D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. First trimester bleeding: Abruptio placentae typically occurs in the third trimester, not the first. First trimester bleeding is more commonly associated with conditions like miscarriage or ectopic pregnancy.
B. Nausea: Nausea is a non-specific symptom of pregnancy and not a hallmark of abruptio placentae. It does not help distinguish this condition from other obstetric complications.
C. Delayed menses: Delayed menses is an early sign of pregnancy, not a finding related to abruptio placentae. It occurs long before the placenta forms and has no diagnostic value in placental abruption.
D. Severe abdominal pain: Abruptio placentae involves premature separation of the placenta from the uterine wall, leading to intense, persistent abdominal pain, uterine tenderness, and often vaginal bleeding. It is a medical emergency requiring immediate intervention.
Correct Answer is ["B","C","E","F","H"]
Explanation
Rationale:
A. Initiate contact precautions: No signs of infection or communicable disease are present, so contact precautions are unnecessary.
B. Decrease lighting in the client’s room: The client is restless and later becomes lethargic, suggesting neurological irritability or worsening preeclampsia. Reducing environmental stimuli like lighting can help minimize seizures and agitation.
C. Check urinary output: The client’s urine output decreased to 20 mL in one hour, which is concerning for renal impairment often seen in severe preeclampsia. Monitoring output closely helps detect worsening kidney function and fluid balance.
D. Prepare for amniocentesis: There is no indication for amniocentesis in this clinical scenario related to preeclampsia or maternal condition.
E. Encourage bed rest: Bed rest in the side-lying position improves uteroplacental perfusion and helps control blood pressure, reducing the risk of complications from preeclampsia.
F. Monitor blood pressure: Blood pressure is elevated and critical to assess frequently to evaluate disease progression and prevent hypertensive emergencies or seizures.
G. Apply internal fetal monitor: The client has no contractions and a stable external fetal heart rate. Internal monitoring is invasive and reserved for active labor or when external monitoring is insufficient.
H. Assess DTR: The shift from hyperreflexia (3+) to hyporeflexia (1+) may indicate worsening neurological status or magnesium sulfate toxicity if administered. Continuous monitoring is essential.
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