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 D
Explanation
Choice A Reason:
Encouraging three large meals daily might not be feasible for someone experiencing malnutrition and decreased appetite. Smaller, more frequent meals or snacks throughout the day could be better tolerated and more beneficial.
Choice B Reason:
Administering an antiemetic after each meal assumes that the client will experience nausea or vomiting regularly after eating. This might not be the case for all clients with AIDS and may not be necessary if the primary issue is malnutrition without associated frequent vomiting.
Choice C Reason:
Seasoning foods with spices might improve the taste of food and potentially stimulate appetite, but it's not as direct or comprehensive a measure for addressing malnutrition as providing a high-calorie diet.
Choice D Reason:
Provide a high-calorie diet is correct. Clients with AIDS often experience malnutrition due to various factors such as decreased appetite, difficulty eating, or malabsorption. Offering a high-calorie diet can help address nutritional deficiencies and support the body's increased energy needs.
Correct Answer is A
Explanation
Choice A Reason:
The client's fingers are cool to the touch is correct. Coolness of the fingers within a short time after a cast application can indicate compromised circulation or potential compartment syndrome, which requires urgent attention to prevent tissue damage or loss of function. It suggests impaired blood flow to the fingers, which is a serious concern requiring immediate evaluation by the provider.
Choice B Reason:
The client reports severe itching under the cast is incorrect. While itching can be uncomfortable, it might not pose an immediate threat. Itching can commonly occur as the skin heals and can be managed through non-invasive means.
Choice C Reason:
The client's capillary refill is 3 seconds is incorrect. A capillary refill of 3 seconds is slightly prolonged but doesn't typically indicates an immediate emergency. However, if this finding worsens or if combined with other concerning symptoms, it might warrant further assessment.
Choice D Reason:
The client reports increased pain at the area of the fracture is incorrect. Increased pain after a cast application can be expected initially, especially within 2 hours of the procedure. However, persistent or severe pain could indicate issues like poor alignment, swelling, or other complications. While it's important to address pain, it might not require immediate reporting unless accompanied by other concerning symptoms.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
