The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?
Encourage the patient to perform as many self-care activities as possible.
Place the patient on bed rest to prevent fatigue.
Coordinate with occupational therapy for gait training.
Provide a complete bed bath to promote patient comfort.
The Correct Answer is A
A. Encouraging self-care helps promote independence and functional recovery in stroke patients, supporting rehabilitation and enhancing self-esteem.
B. Bed rest is not recommended as it can contribute to muscle deconditioning and complications associated with immobility.
C. While coordination with therapy is beneficial, gait training is typically handled by physical therapy rather than occupational therapy.
D. Providing a complete bed bath limits the patient’s autonomy; encouraging partial participation supports the patient's involvement in self-care.
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Correct Answer is C
Explanation
A. Continuing with the injection after seeing blood return increases the risk of injecting into a blood vessel, which is not safe for IM injections.
B. Administering at a slower rate does not address the issue of possible intravascular injection.
C. If blood is aspirated, the correct procedure is to withdraw the needle, dispose of the medication, and prepare a new dose to prevent intravascular administration, as IM injections are meant to be given into muscle tissue, not into a vein.
D. Pulling the needle back slightly is not recommended because it does not ensure that the needle is completely out of the blood vessel.
Correct Answer is C
Explanation
A. Increased cholesterol levels are not directly related to garlic intake or the effects of warfarin.
B. Distended jugular veins may indicate fluid overload or heart failure but are not a direct concern related to warfarin and garlic interaction.
C. Garlic can enhance the anticoagulant effect of warfarin, increasing the risk of bleeding; therefore, monitoring for signs of bleeding is crucial.
D. Angina is not a direct consequence of the interaction between garlic and warfarin and does not specifically relate to the assessment for this patient.