Nokea
Which assessment is critical for a client with a recent stroke?
- A. Swallowing ability.
- B. Blood glucose.
- C. Cholesterol levels.
- D. Joint mobility.
Correct Answer: A
Rationale: Assessing swallowing ability is critical to prevent aspiration in stroke patients.
You may also like to solve these questions
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?
- A. Reverse Trendelenburg.
- B. Low Fowler’s.
- C. High lithotomy.
- D. Prone.
Correct Answer: C
Rationale: The client is in the lithotomy position. The reverse Trendelenburg position is when the client is lying supine with the head lower than the rest of the body. A low Fowler’s position is when the client is sitting up at a 30- to 45-degree angle. The prone position is when the client is lying face down.
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?
- A. The rehabilitation plan will be guided by it.
- B. Functional status before the stroke will help predict outcomes.
- C. It will help the client recognize his physical limitations.
- D. The client can be expected to regain much of his functioning.
Correct Answer: A
Rationale: A pre-stroke functional status history guides the rehabilitation plan by setting realistic goals based on prior abilities. Predicting outcomes, recognizing limitations, or expecting full recovery are secondary or unrealistic.
The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which of the following symptoms?
- A. Heartburn.
- B. Jaundice.
- C. Anorexia.
- D. Stomatitis.
Correct Answer: A
Rationale: Heartburn is a hallmark symptom of a sliding hiatal hernia with reflux, caused by stomach acid refluxing into the esophagus.
A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:
- A. An air embolus.
- B. A pneumothorax.
- C. A pulmonary embolus.
- D. A myocardial infarction.
Correct Answer: B
Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.
A client with a recent total knee replacement reports swelling in the operative leg. Which nursing action is most appropriate?
- A. Elevate the leg on two pillows.
- B. Apply a warm compress to the knee.
- C. Encourage immediate ambulation.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Elevating the leg reduces swelling by promoting venous return, a standard post-surgical intervention.