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A nurse working on a medical-surgical unit is developing a discharge plan for a client who has left-sided hemiplegia following a stroke. Which of the following actions is the nurse’s priority?

Consult with a case manager about insurance coverage.

Counsel caregivers about respite care options.

Refer the client to a local stroke support group.

Ensure that the client has a referral for physical therapy.

Answer and Explanation

The Correct Answer is D

A. Financial planning is important but not the immediate safety priority.

B. Respite care supports caregivers but does not directly impact client safety or recovery.

C. Support groups assist with long-term coping, not early functional recovery.

D. Physical therapy is essential for a client with hemiplegia to prevent contractures, improve mobility, and promote independence. Early rehabilitation enhances recovery and prevents complications such as deep vein thrombosis and muscle atrophy.

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Correct Answer is C

Explanation

Rationale:

A. The client is doing 30 min of moderate exercise daily: Regular moderate exercise (e.g., walking, swimming) is recommended in pregnancy. It improves circulation, mood, and endurance for labor.

B. The client last visited the dentist 4 months ago: Dental care is encouraged during pregnancy because hormonal changes increase the risk of gingivitis. A dental visit 4 months ago is appropriate.

C. The client started working in a parking garage 3 months ago: Parking garages have poor ventilation and potential exposure to carbon monoxide (CO) from car exhaust, which can cause fetal hypoxia and developmental harm. The nurse should assess environmental safety and possibly recommend reassignment.

D. The client is drinking 2.5 L of water per day: Adequate hydration is essential in pregnancy to maintain amniotic fluid volume and prevent dehydration.

A. Prefers foods that maintain a balance of hot and cold within the body. B. Tends to be very expressive with gestures and body language C. Expresses pain freely and loudly D. Prefers to make direct eye contact with health care personnel

Correct Answer is A

Explanation

A. In traditional Chinese medicine, health is viewed as a balance between yin (cold) and yang (hot) forces. After childbirth (a "cold" state), women typically consume "hot" foods to restore balance.

B. Chinese culture values emotional restraint and modesty; expressive gestures are less common.

C. Pain is often endured quietly as a sign of strength and self-control.

D. Avoiding direct eye contact is a sign of respect, not avoidance.

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A nurse working on a medical-surgical unit is developing a discharge plan for a client who has left-sided hemiplegia following a stroke. Which of the following actions is the nurse’s priority?

Nursing Test Bank

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