An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?
Facilitate a consultation for speech therapy.
Arrange for daily home care assistance.
Use pictures and gestures to communicate.
Initiate passive range of motion exercises.
The Correct Answer is A
A. Facilitate a consultation for speech therapy: Aphasia and difficulty swallowing are common after a CVA. A speech therapist can assess and provide interventions to address both speech and swallowing issues, improving communication and reducing the risk of aspiration or choking.
B. Arrange for daily home care assistance: While home care assistance may be necessary later, the immediate priority is addressing the client's communication and swallowing difficulties through therapy and clinical interventions.
C. Use pictures and gestures to communicate: This is helpful for the client’s communication, but it should be seen as an adjunct to speech therapy, not a substitute. Speech therapy provides targeted interventions to improve both speech and swallowing.
D. Initiate passive range of motion exercises: Although range of motion exercises are important for preventing joint contractures and promoting mobility, addressing the client’s swallowing and communication issues is a more immediate priority.
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Related Questions
Correct Answer is B
Explanation
A. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: This is appropriate, but not the most immediate priority. Isolation must occur first to prevent viral spread before formal reassignment can be made.
B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE: This is the most urgent infection control measure. Isolation limits transmission risk while awaiting test results and is the first step in managing suspected COVID-19 cases.
C. Explain to the client to inform others that they may have been potentially exposed in the last 14 days: This is part of public health tracing but is not the nurse’s immediate clinical priority when caring for a symptomatic client.
D. Update the client and family regarding the COVID-19 vaccines that are available: Vaccine education is important for prevention but not urgent during symptomatic evaluation and isolation of a potentially infectious individual.
Correct Answer is D
Explanation
A. Abdominal cramping: Abdominal cramping can be a common symptom of gastritis and may not necessarily require immediate reporting unless it is severe or accompanied by other concerning symptoms.
B. Low grade fever: A low-grade fever can occur with gastritis as part of the inflammatory response, but it is not an immediate concern unless it persists or worsens. It is generally not as urgent as other symptoms.
C. Bruising of the skin: Bruising is not a typical symptom of gastritis. It may be indicative of a bleeding disorder or other underlying issues unrelated to the gastrointestinal system. However, it is not directly associated with gastritis.
D. Bloody emesis: Bloody emesis (vomiting blood) is a critical sign that indicates possible gastrointestinal bleeding, which can occur with severe gastritis. This is an emergency situation and should be reported immediately as it requires urgent medical attention.
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