Nokea
The nurse is caring for a client who has had a stroke. Which nursing intervention is most appropriate to prevent contractures in the affected limbs?
- A. Perform passive range-of-motion exercises daily.
- B. Apply splints to the affected limbs continuously.
- C. Encourage the client to perform active exercises hourly.
- D. Massage the affected limbs every 4 hours.
Correct Answer: A
Rationale: Passive range-of-motion exercises prevent contractures by maintaining joint mobility in clients with stroke-related paralysis.
You may also like to solve these questions
Which instruction is most applicable after symptoms are relieved?
- A. Carry heavy objects away from your center of gravity.
- B. Lift with your knees bent and your back straight.
- C. Create a base of support by keeping your feet together.
- D. Select a soft, spongy mattress for your bed.
Correct Answer: B
Rationale: Lifting with knees bent and back straight prevents re-injury to the lumbar spine after a herniated disk.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
- A. An oral anticoagulant medication.
- B. A beta blocker medication.
- C. An anti-hyperuricemic medication.
- D. A thrombolytic medication.
Correct Answer: A
Rationale: A TIA in a client with atrial fibrillation is likely due to cardioembolic stroke risk. Oral anticoagulants (A), such as warfarin or direct oral anticoagulants, are prescribed to prevent clot formation. Beta blockers (B) control heart rate, anti-hyperuricemics (C) treat gout, and thrombolytics (D) are used acutely, not for discharge prevention.
Which nursing action would be most appropriate if the client develops anorexia and nausea while taking interferon beta-1a (Avonex)?
- A. Withhold the medication.
- B. Offer frequent mouth care.
- C. Administer the drug after meals.
- D. Provide small, easy to digest meals.
Correct Answer: D
Rationale: Providing small, easy-to-digest meals helps manage nausea and encourages nutritional intake without altering the medication schedule.
Which assessment finding in a client post-diskectomy indicates a potential complication?
- A. Mild incisional pain
- B. Numbness in the toes
- C. Clear urine output
- D. Stable vital signs
Correct Answer: B
Rationale: Numbness in the toes may indicate nerve compression or damage, a potential complication requiring further evaluation.
Which intervention is most appropriate for a client with multiple sclerosis experiencing fatigue?
- A. Schedule activities in the late afternoon.
- B. Encourage short, frequent rest periods.
- C. Administer caffeine supplements.
- D. Increase physical therapy sessions.
Correct Answer: B
Rationale: Short, frequent rest periods help manage fatigue in multiple sclerosis by conserving energy.