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 C
Explanation
A. Iron-rich meats: While iron is essential for preventing anemia, it does not contribute significantly to bone mineral density. These foods are not a primary recommendation for osteoporosis prevention, which focuses on calcium and vitamin D intake.
B. Water and herbal teas: Adequate hydration is important for overall health, but water and herbal teas do not contain the calcium or vitamin D needed to support bone health. They have minimal direct impact on preventing osteoporosis.
C. Low fat dairy products: Low fat dairy products like milk, yogurt, and cheese are rich in calcium and often fortified with vitamin D—both critical nutrients for maintaining bone density and preventing osteoporosis.
D. Fresh fruits and vegetables: Fruits and vegetables provide general nutritional support, but are not the most concentrated sources of bone-building nutrients like calcium. They support health broadly but are not the key dietary focus for osteoporosis.
Correct Answer is C
Explanation
A. Electromyography: Electromyography assesses electrical activity in muscles and is used to diagnose neuromuscular disorders. It is not relevant to evaluating bleeding tendencies or pinpoint skin spots, which suggest a hematologic issue like thrombocytopenia.
B. Skin biopsy: A skin biopsy might help diagnose dermatologic conditions, but it is invasive and not the initial step when systemic drug side effects like petechiae are suspected. The presence of red spots suggests a possible blood disorder requiring laboratory confirmation first.
C. Complete blood count: A CBC is essential to evaluate for thrombocytopenia, a known adverse effect of zidovudine. Pinpoint red spots, or petechiae, are often linked to low platelet counts, which require prompt detection and management to prevent serious complications.
D. Allergy test: Allergy testing identifies hypersensitivity reactions, typically associated with rashes or itching. Petechiae are not commonly caused by allergic reactions but are more indicative of blood abnormalities, making this test less immediately relevant.
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