A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
"You will not become fatigued when you use assistive devices."
"Plan to hire a home care aid to perform all of your ADLs."
"Install grab bars in your shower to assist with your balance."
"Place a towel in the shower to prevent slipping
The Correct Answer is C
"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.
Choice B Reason:
"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.
While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.
Choice C Reason:
"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.
Choice D Reason:
"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Measuring the client's intake and output every 8 hours is a general nursing intervention but might not be specifically pertinent to managing viral meningitis.
Choice B Reason:
Dim the lighting in the client's room is correct. Meningitis often causes sensitivity to light (photophobia) due to the inflammation of the meninges surrounding the brain and spinal cord. Dimming the lighting in the client's room helps reduce discomfort and sensitivity to light, which is a common symptom of meningitis.
Choice C Reason:
Monitoring the client's temperature every 6 hours is a routine nursing practice, but in viral meningitis, more frequent temperature monitoring might be necessary, especially if the client shows signs of fever or instability.
Choice D Reason:
Initiating contact precautions for viral meningitis is not typically necessary because it's usually transmitted through respiratory secretions. Standard precautions for infection control, including proper hand hygiene, are usually sufficient.
Correct Answer is B
Explanation
Choice A Reason:
Temperature 37.3°C (99.1°F) is incorrect . While a slightly elevated temperature can sometimes accompany an infection, it's not specific to a bladder infection and might not be present in all cases.
Choice B Reason:
Changed mental status is incorrect. Bladder infections or urinary tract infections (UTIs) in older adults can often present with atypical symptoms, and changes in mental status or acute confusion are common indicators in this population. UTIs can cause subtle but significant alterations in mental function, particularly in the elderly, leading to confusion, agitation, or cognitive impairment.
Choice C Reason:
WBC count 9,000/mm3 (5000 to 10,000/mm3) is incorrect .A WBC count within the normal range doesn't necessarily rule out or confirm a bladder infection. In some cases, UTIs might not significantly elevate the white blood cell count, especially in localized infections.
Choice D Reason:
Diminished reflexes is incorrect . Diminished reflexes are not typically associated with a bladder infection. They might indicate other neurological or muscular issues but are not a common sign of a UTI.
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