a nurse is caring for a client who is being discharged home following a cerebrovascular accident which of the following documents should the nurse pla
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 with NGN

1. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

2. What is the appropriate intervention for a patient experiencing hypovolemic shock?

Correct answer: A

Rationale: The correct intervention for a patient experiencing hypovolemic shock is to administer IV fluids. In hypovolemic shock, there is a significant loss of circulating blood volume leading to inadequate perfusion to tissues. Administering IV fluids is crucial to restore blood volume and improve tissue perfusion. Monitoring blood pressure (choice B) is important but not the primary intervention in hypovolemic shock. Placing the patient in Trendelenburg position (choice C) can worsen outcomes by increasing intracranial pressure and is no longer recommended. Administering oxygen (choice D) is beneficial for many conditions but does not address the underlying issue of inadequate circulating blood volume in hypovolemic shock.

3. How should a healthcare professional manage a patient with a suspected deep vein thrombosis (DVT)?

Correct answer: A

Rationale: Corrected DVT management involves administering anticoagulants to prevent clot growth and monitoring for signs of bleeding. Elevating the limb and administering pain relief (Choice B) may help alleviate symptoms but do not address the underlying issue of preventing clot progression. Restricting mobility and applying warm compress (Choice C) could potentially dislodge the clot and worsen the condition. Administering IV fluids and providing bed rest (Choice D) are not primary interventions for managing DVT.

4. What are the key factors in assessing a patient's fall risk?

Correct answer: A

Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.

5. A client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?

Correct answer: D

Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.

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