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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Stridor: Stridor is a high-pitched airway sound typically associated with hypocalcemia due to laryngeal spasms from increased neuromuscular excitability. It is not a common feature of hypercalcemia, where muscle excitability is decreased.

B. Seizure: Seizures result from heightened neuronal activity, which occurs more frequently in hypocalcemia. Hypercalcemia depresses neural and muscular activity, making seizures an unlikely symptom.

C. Elevated hematocrit: Elevated hematocrit can occur with dehydration but is not a direct effect of high serum calcium levels. It is not considered a hallmark manifestation of hypercalcemia.

D. Personality change: Hypercalcemia affects the central nervous system, often leading to confusion, lethargy, or personality changes. These alterations occur due to the depressive effects of excess calcium on brain function.

A. "Can you talk about what was happening with your partner at home?" B. "Why do you think your partner's symptoms are progressing so quickly?” C. "You should make sure your partner takes the prescribed medication” D. "You did the right thing by bringing your partner in for treatment”

Correct Answer is A

Explanation

Rationale:

A. "Can you talk about what was happening with your partner at home?": This open-ended question encourages the partner to express emotions and provide context, which helps build trust and gather relevant information. It’s a therapeutic response that validates the partner’s experience without judgment or assumptions.

B. "Why do you think your partner's symptoms are progressing so quickly?” This question may come off as accusatory or put the partner on the defensive. "Why" questions can create a sense of blame or pressure, which is not conducive to a supportive therapeutic environment.

C. "You should make sure your partner takes the prescribed medication”: This directive may be perceived as dismissive and does not acknowledge the partner’s emotional distress. While medication adherence is important, this is not the most therapeutic or empathetic initial response.

D. "You did the right thing by bringing your partner in for treatment”: While affirming the decision is supportive, this response closes the conversation and doesn’t invite the partner to explore their concerns or emotions further, limiting therapeutic dialogue.

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A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to teach a group of newly licensed nurses about hypercalcemia. Which of the following manifestations should the nurse Include in the teaching?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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