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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["75"]
Explanation
Dose per administration in milliliters = 15 mL.
Concentration of the medication = 12.5 mg/5 mL.
- Calculate the amount of medication in milligrams (mg) per administration.
Amount per administration (mg) = Dose per administration (mL) × (Concentration (mg) / Volume (mL))
= 15 mL × (12.5 mg / 5 mL)
= 15 mL × 2.5 mg/mL
= 37.5 mg.
- Determine the number of doses per day.
Doses are given every 12 hours, so Number of doses per day = 24 hours / 12 hours/dose
= 2 doses/day.
- Calculate the total daily dose in milligrams (mg).
Total daily dose (mg) = Amount per administration (mg) × Number of doses per day
= 37.5 mg × 2 doses
= 75 mg.
Correct Answer is C
Explanation
A. Suggest to the client that he take a walk: Allowing pacing might escalate the agitation or delusions, especially in a stimulating environment. This does not address the immediate need to reduce stimuli.
B. Use firmness and direct the client to sit for a while: Direct commands may increase the client's agitation or trigger a confrontation if the client feels threatened or challenged while delusional.
C. Move the client to a quiet place on the unit: Reducing environmental stimuli by relocating the client to a low-stimulation setting can help de-escalate the situation and prevent further loss of control.
D. Encourage the client to use the punching bag: Promoting physical aggression even if directed at an object may reinforce violent behavior and is inappropriate during acute delusional episodes.
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