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:
Ensure the blinds in the client's room remain open is not appropriate. Bright light can contribute to sensory overload. It's better to create a subdued and calming environment, so keeping the blinds closed or partially closed might help reduce excess stimuli.
Choice B Reason:
Place the client in a room near the nurses' station is not appropriate. Being near the nurses' station could increase the noise and activity around the client, potentially worsening sensory overload. It's advisable to place the client in a quieter area away from high-traffic zones to minimize auditory and visual stimulation.
Choice C Reason:
Play quiet music in the client's room is incorrect. While soothing music might help some individuals relax, for someone experiencing sensory overload, even low-volume music could add to the stimuli. Silence or minimal ambient noise might be more beneficial.
Choice D Reason:
Break up nursing care into small, frequent sessions is correct. This action is beneficial for managing sensory overload. Breaking up care into smaller sessions allows for adequate rest periods between activities, reducing the overall sensory input at any given time.
Correct Answer is D
Explanation
Choice A Reason:
3 oz chicken breast is incorrect. Chicken breast contains iron, but its iron content is generally lower compared to red meats like beef. It contains less heme iron, which is more readily absorbed by the body, compared to the iron in red meats.
Choice B Reason:
3 oz canned tuna is incorrect. Tuna is a good source of protein but doesn't contain as much iron as red meats. While it does have some iron content, it's generally lower compared to red meats like ground beef.
Choice C Reason:
3 oz pork roast is incorrect. Pork contains iron, but its iron content might not be as high as that found in red meats like ground beef. The specific cut and preparation method can also affect the iron content, but generally, pork might not provide as much iron as beef.
Choice D Reason:
3 oz ground beef is correct. Red meat, like ground beef, generally contains higher amounts of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based sources. This makes ground beef a good source of iron for individuals with iron-deficiency anemia.
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