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 B
Explanation
Rationale:
A. "This surgery can cause an increase in the amount of semen.":A transurethral resection of the prostate (TURP) often results in retrograde ejaculation, meaning semen may flow backward into the bladder. The volume of visible semen typically decreases, not increases, due to this common complication.
B. "I will talk to my partner about other ways of expressing intimacy.":This statement reflects healthy psychological adjustment and understanding of potential changes in sexual function following TURP. It shows emotional readiness to adapt to changes and maintain intimacy in ways beyond penetrative sex, which supports recovery and relationship stability.
C. “I will not be able to have sexual intercourse after this surgery.":TURP does not prevent sexual intercourse. While temporary issues like erectile dysfunction or retrograde ejaculation may occur, most clients can resume sexual activity after recovery. This belief represents a misunderstanding of surgical outcomes.
D. “This surgery will prevent me from being able to have an erection.": Although some men may experience temporary erectile dysfunction postoperatively, TURP typically does not cause permanent loss of erectile function. Misconceptions about impotence should be addressed through accurate education.
Correct Answer is A
Explanation
Rationale:
A. Check for seals in the drainage system: Urinary leakage in a client with an indwelling catheter may indicate a break in the closed drainage system. Inspecting for disconnected or loose seals is essential to verify the system’s integrity and ensure proper catheter function, reducing the risk of backflow or infection.
B. Place a waterproof pad under the client's buttocks: This action addresses the symptom of leakage rather than identifying or correcting the cause. While it may help manage moisture, it does not ensure the catheter is functioning properly or prevent further complications.
C. Clip the drainage tubing to the edge of the mattress: Clipping the tubing can obstruct flow and increase the risk of urine retention or reflux. Tubing should be secured loosely and not kinked, with no tension that might disrupt drainage or lead to malfunction.
D. Position the drainage bag below the level of the client's bladder: While proper bag positioning is important to promote gravity drainage, it does not specifically verify safe functioning if leakage is occurring. Ensuring the drainage system is intact is the first step in evaluating catheter function.
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