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: Encouraging the family to join a support group is not the first action that the nurse should take. This is an important intervention that can help the family cope with the challenges and stress of caring for a client who has dementia, but it should be done after the nurse has established rapport and trust with the family.
Choice B reason: Providing the family with information about respite care is not the first action that the nurse should take. This is an important intervention that can help the family access temporary relief from their caregiving responsibilities, but it should be done after the nurse has assessed the family's needs and preferences.
Choice C reason: Educating the family regarding the progression of dementia is not the first action that the nurse should take. This is an important intervention that can help the family understand the nature and course of the disease, and prepare them for the future changes and challenges, but it should be done after the nurse has evaluated the family's level of knowledge and readiness to learn.
Choice D reason: Engaging the family in informal conversation is the first action that the nurse should take. This is based on the principle of communication, which states that the nurse should initiate and maintain a therapeutic relationship with the client and the family. The nurse should use informal conversation to introduce herself, express interest and empathy, and create a comfortable and respectful atmosphere. The nurse should also use open-ended questions, active listening, and nonverbal cues to elicit the family's concerns, expectations, and goals.
Correct Answer is B
Explanation
Choice A reason: Creating diversionary activities for children is not the priority action for the nurse to take. This is a supportive intervention that can help the children cope with the stress and trauma of the disaster, but it should be done after the nurse has ensured the safety and well-being of the clients.
Choice B reason: Addressing the physical needs of clients is the priority action for the nurse to take. This is based on the principle of Maslow's hierarchy of needs, which states that the nurse should prioritize the most basic and essential needs of the clients, such as food, water, shelter, clothing, and medical care. The nurse should assess the clients for any injuries, illnesses, or chronic conditions, and provide appropriate interventions or referrals.
Choice C reason: Helping clients gather needed supplies is not the priority action for the nurse to take. This is a helpful intervention that can assist the clients to obtain the resources and materials they need to survive and recover from the disaster, but it should be done after the nurse has addressed the physical needs of the clients.
Choice D reason: Exploring feelings the clients are experiencing is not the priority action for the nurse to take. This is a therapeutic intervention that can facilitate the emotional and psychological healing of the clients, but it should be done after the nurse has addressed the physical needs of the clients. The nurse should also respect the clients' readiness and willingness to share their feelings, and avoid forcing or rushing the process.
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