A home health nurse is visiting a client who had a stroke 2 months ago. Which of the following findings should the nurse report to the interprofessional care team?
The client dresses her affected side first.
The client bears weight on their arms when using crutches.
The client coughs when swallowing her medications.
The client's caregiver fills a pill organizer weekly.
The Correct Answer is C
Choice A reason: The client dressing her affected side first is not a finding that the nurse should report to the interprofessional care team, as it indicates that the client is following the proper technique for dressing after a stroke. Dressing the affected side first helps the client maintain range of motion and prevent contractures of the affected limbs.
Choice B reason: The client bearing weight on their arms when using crutches is not a finding that the nurse should report to the interprofessional care team, as it is a normal and expected way of using crutches. Bearing weight on the arms helps the client balance and support their body weight while walking with crutches.
Choice C reason: The client coughing when swallowing her medications is a finding that the nurse should report to the interprofessional care team, as it indicates that the client may have dysphagia, or difficulty swallowing, which is a common complication of stroke. Dysphagia can increase the risk of aspiration, pneumonia, dehydration, and malnutrition. The nurse should assess the client's swallowing ability and refer them to a speech-language pathologist for further evaluation and intervention.
Choice D reason: The client's caregiver filling a pill organizer weekly is not a finding that the nurse should report to the interprofessional care team, as it is a positive and helpful way of managing the client's medications. Filling a pill organizer weekly can help the client and the caregiver remember the medication names, doses, and schedules, and prevent medication errors or omissions.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Implementing a disaster triage plan with a local medical facility is not an action that the nurse is engaging in disaster preparedness efforts. This is an action that the nurse is engaging in disaster response efforts, which are the actions taken during or immediately after a disaster to save lives, minimize injuries, and protect property.
Choice B reason: Functioning as a manager at a temporary shelter is not an action that the nurse is engaging in disaster preparedness efforts. This is an action that the nurse is engaging in disaster recovery efforts, which are the actions taken after a disaster to restore the normal functioning of the community and the environment.
Choice C reason: Assisting with the identification of a biological agent is not an action that the nurse is engaging in disaster preparedness efforts. This is an action that the nurse is engaging in disaster mitigation efforts, which are the actions taken before, during, or after a disaster to reduce or eliminate its impact.
Choice D reason: Organizing a mass casualty drill for community members is an action that the nurse is engaging in disaster preparedness efforts. This is an action that the nurse is engaging in disaster prevention efforts, which are the actions taken before a disaster to prevent or minimize its occurrence or effects. A mass casualty drill is a simulation exercise that tests the readiness and capacity of the health care system and the community to respond to a large-scale emergency.
Correct Answer is C
Explanation
Choice A reason: Presenter's teaching strategies are not the factor that will have the greatest effect on the success of the class. Although the presenter should use effective and appropriate teaching methods that suit the learning objectives and outcomes, the teaching strategies alone cannot guarantee the success of the class if the client is not motivated to quit smoking.
Choice B reason: Presenter's credibility is not the factor that will have the greatest effect on the success of the class. Although the presenter should have the knowledge, skills, and experience to deliver the smoking cessation education, the presenter's credibility alone cannot ensure the success of the class if the client is not motivated to quit smoking.
Choice C reason: Client's motivation is the factor that will have the greatest effect on the success of the class. Motivation is the driving force that influences the client's behavior and actions. The client's motivation to quit smoking can be influenced by various factors, such as personal, social, environmental, or health-related reasons. The presenter should assess the client's motivation level, and use strategies to enhance and sustain it throughout the class.
Choice D reason: Client's education level is not the factor that will have the greatest effect on the success of the class. Although the presenter should consider the client's education level when designing and delivering the smoking cessation education, the client's education level alone cannot determine the success of the class if the client is not motivated to quit smoking.
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