An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Place a bedside commode next to bed.

Measure neurological vital signs every 4 hours.

Suction oral cavity every 4 hours.

Encourage family to participate in the client's care.

Play classical music in room while client is

Answer and Explanation

Correct Answer : A,B,D

The correct answer is a. Place a bedside commode next to bed., b. Measure neurological vital signs every 4 hours., d. Encourage family to participate in the client’s care.

Choice A rationale:

Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.

Choice B rationale:

Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.

Choice C rationale:

Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management. Routine suctioning can also cause discomfort and potential injury.

Choice D rationale:

Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process. Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.

Choice E rationale:

Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation. The effectiveness of music therapy can vary based on individual preferences.

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Correct Answer is D

Explanation

A) Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.

D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.

A. The rash is due to distended oil glands that will resolve in a few weeks. B. This rash is characteristic of a medication reaction. C. The healthcare provider is being notified about the rash. D. This is a common newborn rash that will resolve after several days.

Correct Answer is D

Explanation

The rash described, pink papular rash with vesicles, is consistent with erythema toxicum neonatorum, which is a common skin condition that affects up to 50% of newborns. It typically appears within the first few days of life and resolves without treatment within 5-7 days. The rash is benign and does not require any specific treatment or intervention.

The rash is not due to distended oil glands or a medication reaction, and there is no indication in the scenario that the healthcare provider needs to be notified about the rash. Erythema toxicum neonatorum is a self-limited condition that resolves on its own, so reassurance and education for the parents are appropriate interventions.

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An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

Correct Answer is D

Explanation

The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

Correct Answer is D

Explanation

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