A nurse is reinforcing teaching about activities of daily living with a client who had a stroke. Which of the following statements should the nurse include?
"Rest in supine position for 30 minutes after a meal."
"Dress the affected side first
"Use the arm on your affected side to brush your hair."
"Use a straw when you drink liquids."
The Correct Answer is B
Rationale:
A. "Rest in supine position for 30 minutes after a meal.": Lying flat after a meal increases the risk of aspiration particularly in stroke clients who may have impaired swallowing. A more upright position should be encouraged during and after meals to reduce this risk.
B. "Dress the affected side first.": Dressing the affected side first promotes independence and makes the task easier by minimizing the need for fine motor coordination on the impaired side. It also reduces frustration and helps establish a safe, consistent dressing routine.
C. "Use the arm on your affected side to brush your hair.": Stroke often leads to muscle weakness or paralysis on one side, making it difficult or unsafe to perform tasks with the affected limb. Initially, clients should use their stronger arm while the affected side is supported and rehabilitated gradually.
D. "Use a straw when you drink liquids.": Using a straw can increase the risk of aspiration in clients with post-stroke dysphagia by promoting rapid fluid intake. It is generally contraindicated until a swallowing assessment confirms that it is safe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A.Provide the caregiver with information on behavior therapy: Behavior therapy is a first-line, evidence-based nonpharmacologic intervention for ADHD, particularly in children. Educating caregivers about behavioral strategies helps improve symptom management and supports long-term success.
B. Screen the child for depression prior to initiating the medication: Although screening for comorbid conditions like depression is important in ADHD management, it is typically part of the initial diagnostic workup, which was already completed with neurology and developmental evaluations.
C. Monitor liver function test results while the child is taking the medication: Atomoxetine carries a risk of rare but serious liver toxicity. Regular monitoring of liver function is essential during treatment, especially if the child shows signs of liver dysfunction (e.g., dark urine, abdominal pain, jaundice).
D. Monitor the child for nightmares while taking the medication: Sleep disturbances, including insomnia and nightmares, are known side effects of atomoxetine. Nurses should monitor and educate caregivers about possible changes in sleep behavior while the child is on this medication.
E.Monitor the child's blood pressure at each visit: Atomoxetine can cause increases in blood pressure and heart rate. Routine monitoring of vital signs at follow-up visits is necessary to ensure cardiovascular safety during treatment.
Correct Answer is D
Explanation
Rationale:
A. Erythema toxicum: This is a common and benign rash seen in newborns. It is not infectious, poses no public health risk, and does not require mandatory reporting.
B. Bacterial vaginosis: Although it is a vaginal infection, bacterial vaginosis is not classified as a reportable condition. It does not pose the same level of public health concern as sexually transmitted infections like gonorrhea.
C. Molluscum contagiosum: Molluscum contagiosum is a viral skin infection that is generally self-limiting and not considered a reportable disease. It does not require public health intervention in most cases.
D. Gonorrhea: Gonorrhea is a nationally notifiable disease in many countries, including the United States, due to its infectious nature and potential for serious complications. Public health reporting is required to track, treat, and prevent its spread.
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