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 A
Explanation
A. The tuberculin test is administered intradermally, and the needle should be inserted at a 15-degree angle to ensure the medication is delivered just under the surface of the skin.
B. A 90-degree angle is used for intramuscular injections, not for intradermal tests like the tuberculin test.
C. A 30-degree angle is commonly used for subcutaneous injections and is too deep for an intradermal injection.
D. A 45-degree angle is also used for subcutaneous injections but is not suitable for intradermal injections.
Correct Answer is C
Explanation
A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.