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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

Rationale:

Drooling: Drooling is classic in epiglottitis due to severe throat pain and an inability to swallow. It is not commonly seen in RSV or streptococcal pharyngitis, where swallowing remains relatively intact.
Hypoxia: Both epiglottitis and RSV can cause hypoxia. In epiglottitis, airway obstruction can quickly compromise oxygenation. In RSV, hypoxia results from inflammation and mucus plugging in the small airways.
Fever: Fever is a nonspecific but common finding across all three conditions. It signals an inflammatory or infectious process, whether viral (RSV), bacterial (Streptococcus), or in epiglottitis (often Haemophilus influenzae type b if unimmunized).
Tachypnea: Tachypnea may occur in both epiglottitis and RSV as the body compensates for airway compromise and impaired gas exchange. It is not a typical feature of uncomplicated streptococcal pharyngitis.
Exudate on pharynx: Pharyngeal exudates are common in streptococcal pharyngitis and help differentiate it from viral causes. They are typically absent in RSV and epiglottitis, where the pathology lies elsewhere (lower airways or supraglottic structures).
Wheezing upon auscultation: Wheezing is a hallmark of RSV due to bronchiolar inflammation and narrowing. It is not seen in epiglottitis or streptococcal pharyngitis, as those conditions do not primarily affect the bronchioles.

A. Ritualistic behavior B. Suspicious of others C. Exhibits separation anxiety D. Preoccupied with aging

Correct Answer is D

Explanation

Rationale:

A. Ritualistic behavior: Ritualistic or compulsive behaviors are most commonly associated with obsessive-compulsive personality disorder or obsessive-compulsive disorder, not narcissistic personality disorder.

B. Suspicious of others: Suspiciousness and distrust are hallmark features of paranoid personality disorder. While individuals with narcissistic traits may be sensitive to criticism, they are not generally suspicious in a paranoid sense.

C. Exhibits separation anxiety: Separation anxiety and fear of being alone are typically seen in dependent personality disorder and sometimes borderline personality disorder, not narcissistic personality disorder.

D. Preoccupied with aging: Clients with narcissistic personality disorder are often highly concerned with maintaining a youthful and admired image. They may fear aging due to its association with loss of beauty, status, or power, making this the expected finding.

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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

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"},"E":{"answers":"C"},"F":{"answers":"B"}}

Explanation

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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