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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Report any increase in the white blood cell count: While monitoring for signs of infection is important, an increase in WBC count alone does not address the risk of MRSA recurrence in the wound. Early intervention with infection control measures is more important.

B. Change the surgical dressing readily when soiled: Changing the dressing when soiled is necessary for wound hygiene but does not target MRSA recurrence. Adhering to infection control measures, like contact precautions, is more effective in preventing MRSA.

C. Instruct the family to adhere to contact precautions: Educating the family on contact precautions is critical for preventing the spread and recurrence of MRSA, especially in the postoperative period. It reduces the risk of contamination and protects both the patient and healthcare workers.

D. Wear a face mask while performing wound care: Wearing a face mask is not necessary for preventing MRSA transmission in the wound care setting. Contact precautions, including proper hand hygiene and wearing gloves, are more effective for MRSA prevention.

A. Electrolytes B. Coagulation studies C. Blood culture D. Lipid panel E. Complete blood count F. Urine osmolality G. Arterial blood gas H. Type and screen

Correct Answer is ["A","B","E","G","H"]

Explanation

A. Electrolytes: Electrolytes are important to monitor in this client due to potential blood loss and altered kidney function. Electrolyte imbalances (especially sodium and potassium) can affect heart function, muscle strength, and overall fluid balance, which is crucial after trauma and surgery.

B. Coagulation studies: Given the trauma (liver and spleen lacerations), the client is at risk for bleeding. Coagulation studies (including PT, INR, and aPTT) are necessary to assess the clotting ability and manage bleeding risk, particularly before surgery or when planning for interventions.

C. Blood culture: While blood cultures are important for identifying infections, there is no immediate indication of infection in this patient at this point in time. The priority is stabilizing the patient and managing trauma and bleeding.

D. Lipid panel: A lipid panel is not a priority at this moment. It is generally used to assess cardiovascular risk and would not provide immediate information relevant to managing acute trauma and bleeding.

E. Complete blood count (CBC): A CBC is essential to assess for anemia, infection, or other hematologic abnormalities, especially in trauma patients with possible internal bleeding. Hemoglobin and hematocrit levels provide information about blood loss and oxygen-carrying capacity.

F. Urine osmolality: Urine osmolality is useful for assessing kidney function and hydration but is not immediately necessary in this trauma case. The priority is stabilizing the patient's circulatory and respiratory status, with more focus on urine output and renal function.

G. Arterial blood gas (ABG): An ABG is crucial to assess the client’s oxygenation, ventilation, and acid-base status, especially since the client is intubated and on a ventilator. This will help in monitoring respiratory function and ensuring proper oxygen delivery.

H. Type and screen: The client has a history of trauma and potential internal bleeding. It is essential to know her blood type and ensure compatibility for any potential blood transfusions, particularly before the exploratory laparotomy and any possible further blood loss.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Exhibits Which laboratory tests would be helpful in determining the plan of care for this client? Select all that apply.

Correct Answer is ["A","B","E","G","H"]

Explanation

Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to addressdropdown. In addition, he will need interventions to preventdropdown.

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A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notices that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement?