A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke.
Which of the following actions by the nurse best promotes communication among staff caring for the client?
Posting swallowing precautions at the head of the client’s bed
Noting changes in the treatment plan in the client’s medical record.
Having interdisciplinary team meetings for the client on a regular basis
Recording the client’s progress in the nurses’ notes
The Correct Answer is C
Having interdisciplinary team meetings for the client on a regular basis.
This action best promotes communication among staff caring for the client because it allows for consistent and coordinated care planning, information sharing, and goal setting for the client who has expressive aphasia and right hemiparesis following a stroke.
Choice A is wrong because posting swallowing precautions at the head of the client’s bed does not promote communication among staff, but rather informs them of the client’s risk of aspiration due to dysphagia, which is a common complication of stroke.
Choice B is wrong because noting changes in the treatment plan in the client’s medical record is a standard practice that does not necessarily enhance communication among staff, but rather documents the client’s progress and interventions.
Choice D is wrong because recording the client’s progress in the nurses’ notes is also a standard practice that does not necessarily enhance communication among staff but rather provides a summary of the client’s status and care.
Expressive aphasia is an acquired language disorder that affects the ability to produce spoken or written language, while right hemiparesis is a weakness or partial paralysis of the right side of the body.
Both of these conditions are caused by damage to the left hemisphere of the brain, which is responsible for language and motor control of the right side of the body. Stroke and traumatic brain injury are common causes of left hemisphere-damage
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceb. Waits for 2 min between suctions.
Choice A rationale:
Inserting the catheter without applying suction is correct. Suction should only be applied while withdrawing the catheter to prevent trauma to the tracheal mucosa.
Choice B rationale:
Waiting for 2 minutes between suctions is too long.The appropriate wait time is generally around 20-30 seconds to 1 minute between suction attempts to prevent hypoxia and allow the patient to recover.
Choice C rationale:
Applying suction for 15 seconds is within the recommended duration.Suctioning should not exceed 15 seconds to avoid causing hypoxia and trauma to the tracheal mucosa.
Choice D rationale:
Encouraging the client to cough during suctioning is appropriate.Coughing helps to mobilize secretions and can make suctioning more effective.
Correct Answer is D
Explanation
The correct first action for the charge nurse to take in response to an increase in facility-acquired catheter infections is toidentify possible precipitating factors related to the infections. This is because understanding the root cause of the problem is crucial before implementing any changes or interventions. By identifying the factors contributing to the increase in infections, the nurse can then develop targeted strategies to address these specific issues.
Now, let’s discuss why the other options are not the first actions to take:
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Schedule nursing staff training for infection control procedures: While training is important, it should be based on identified needs. Without first understanding the precipitating factors of the increased infections, the training may not address the actual issues at hand.
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Meet with providers to discuss measures to decrease the infections: This could be a subsequent step after identifying the precipitating factors. Meeting with providers without concrete data or understanding of the problem may lead to ineffective solutions.
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Revise the current policy for catheter care: Policy revision should be based on evidence and identified needs. It would be premature to revise policies without first understanding what factors are contributing to the increase in infections.
In summary, the first step in addressing a problem is always to understand its causes. Only then can effective solutions be developed and implemented.
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