Author Question: Hourly neurovital signs have been ordered for a client who has been admitted after experiencing an ... (Read 35 times)

D2AR0N · **on:** Jul 22, 2018

Hourly neurovital signs have been ordered for a client who has been admitted after experiencing an ischemic stroke. The client's neurological status has declined over the past few hours.

Which nursing action best prevents an adverse outcome in this client's care?
A) initiating rehabilitation as soon as possible
B) arranging for STAT computed tomography of the client's head
C) documenting any changes in the client's status in a detailed and timely manner
D) assessing the client's neurological status more frequently than ordered

Question 2

A client is being treated for community-acquired pneumonia and has experienced respiratory distress and hypoxia on several occasions since being admitted. The nurse can best prevent adverse outcomes during this client's care by:

A) collaborating closely with members of the interdisciplinary team.
B) vigilantly monitoring the client's oxygenation status.
C) involving the client when identifying goals for care.
D) educating the client about self-care as it relates to respiratory health.

bulacsom · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

Ans: D
Feedback:
Frequent assessment is integral to the detection of changes in a client's status and in the prevention of adverse outcomes. Assessing a client more frequently than ordered is an appropriate independent nursing action. Documentation is an essential part of nursing care, but does not directly prevent adverse health outcomes. A CT of the client's head may or may not be necessary, and would not be independently ordered by the nurse. Early rehabilitation promotes functional recovery, but does not prevent adverse outcomes during care.

Answer to Question 2

Ans: B
Feedback:
All of the listed actions are appropriate to the care of this client. However, close monitoring and early detection of changes are paramount in the prevention of adverse outcomes. Frequent and careful assessment is a priority.