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 ["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.

A. Assess for signs of urine retention. B. Inspect epidural catheter insertion site. C. Monitor the client's dermatome level for sensation. D. Inquire if the client is experiencing breakthrough pain.

Correct Answer is C

Explanation

A. Assess for signs of urine retention: While important, urinary retention is a later complication. It does not take priority over assessing for potentially serious effects like respiratory depression or excessive spread of anesthesia.

B. Inspect epidural catheter insertion site: Inspecting the site helps identify infection or dislodgement but is not the first priority. Neurological and respiratory assessments take precedence due to fentanyl’s CNS effects.

C. Monitor the client's dermatome level for sensation: This assesses the spread of the anesthetic, ensuring it hasn’t ascended to high thoracic levels, which could depress respiration. It’s the most urgent check for client safety.

D. Inquire if the client is experiencing breakthrough pain: Pain assessment is critical, but ensuring safe levels of sensory block must come first to rule out excessive anesthetic spread or complications.

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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

An adult client receives a prescription for diphenhydramine 15 mL PO every 12 hours PRN for pruritus. The bottle is labeled, "Diphenhydramine 12.5 mg/5 mL." What is the total daily dose in mg that the client receives? (Enter numerical value only.)

Correct Answer is ["75"]

Explanation

The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

Correct Answer is C

Explanation

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The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?