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
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.
You might also like to view...
NANDA International meets to reorganize diagnosis labels and language every ______ years
ANS:
A nursing intervention that helps build trust, encourages the patient to have faith in the care being received, and meets psychosocial needs is
a. developing a care plan. b. implementing nurse orders. c. patient education. d. meeting patient goals.
Individuals diagnosed with AIDS often have a wide variety of emotional and psychological responses to the diagnosis, including all except which of the following?
A) A loss of self-esteem B) A fear of the loss of physical attractiveness C) A potential for forming a closer family relationship D) An overwhelming sense of hopelessness and helplessness
If a patient is experiencing shortness of breath, profuse perspiration, and chest pain, he/she is probably experiencing
A) seizure. B) stroke. C) cardiac arrest. D) heart attack.