The home health nurse is teaching fall prevention to a client diagnosed with Parkinson’s disease and has developed the nursing diagnosis of “Risk for Injury related to bradykinesia.” Which intervention is most appropriate for this client?

The nurse has an order to assess a client’s residual urine. Which of these actions is most appropriate?

The nurse would assess for additional signs and symptoms of renal calculi in the client reporting which symptom?

The nurse would assess for additional signs and symptoms of renal calculi in the client reporting which symptom?

The nurse recognizes that which type of stroke would be contraindicated to receive IV fibrinolytic therapy?

A nurse is working in a long-term care facility and notices changes in a 76-year-old client.  The nurse suspects the client is having an acute stroke.  New data: The nurse, who noticed the sudden onset of symptoms (from the previous question) calls 911.  EMS arrives and transports the client to the emergency department (ED).  Based on the client’s symptoms of an acute stroke, which diagnostic test will be performed upon arrival to the Emergency Department?  

The nurse is caring for a client with a history of urinary retention related to prostate enlargement.  Urinary retention is currently being treated with an indwelling foley catheter.  The nurse assesses that the urine output is 45 ml per hour. The most appropriate nursing action is?

A client is admitted to the hospital following a tonic-clonic seizure. The client asks the nurse what causes seizures. What is the best response by the nurse? 

The nurse receives an order to begin oral feedings for a client two days after a stroke. What is the first action the nurse should take before feeding the client?

A nurse is working in a long-term care facility and notices changes in a 76-year-old client.  The nurse suspects the client is having an acute stroke.  Which of the following are common manifestations of an acute stroke?(Select all that apply.)