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:
Setting the degree of flexion and extension as tolerated by the client is generally appropriate in a CPM device, but this should be done within the prescribed range recommended by the healthcare provider. Simply allowing the client to adjust the degree of flexion and extension without guidance might lead to overextension or inadequate movement, potentially causing discomfort or hindering recovery.
Choice B Reason:
Padding the CPM device with a thick pillow isn't the recommended approach. CPM devices typically come with appropriate padding to ensure comfort and proper positioning. Using a thick pillow might alter the device's mechanics or cause uneven support, affecting the intended movement of the knee.
Choice C Reason:
Placing the client in high-Fowler's position (sitting upright at a 90-degree angle) isn't a standard or necessary position for using a CPM device after a knee arthroplasty. The client can typically use the CPM device while lying in a comfortable and relaxed position, following the healthcare provider's instructions regarding positioning during CPM therapy.
Choice D Reason:
Aligning the client's joints with the joints on the frame is essential for the correct function of the CPM device. This alignment helps in providing the intended range of motion without causing unnecessary stress or strain on the knee joint.
Correct Answer is A
Explanation
A. Elevate the head of the client's bed for 1 hr after the feeding:Elevating the head of the bed helps prevent aspiration and promotes proper digestion by using gravity to keep the feeding solution in the stomach or jejunum.
B. Administer the feeding solution at a cold temperature: Feeding solutions should be administered at room temperature to prevent gastrointestinal discomfort or cramping.
C. Rotate the jejunostomy tube once per day:
Rotation of the jejunostomy tube is not a standard practice. Jejunostomy tubes are typically secured in place, and rotation is not necessary.
D. Flush the tube with 90mL of sterile water before and after the feeding:
Typically, the tube is flushed with about 30 mL of water before and after feedings to ensure patency and prevent clogging, not 90 mL.
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