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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?

A.

Facilitate a consultation for speech therapy.

B.

Arrange for daily home care assistance.

C.

Use pictures and gestures to communicate.

D.

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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Related Questions

Correct Answer is B

Explanation

A. While the presence of greenish fluid in a nasogastric tube can indicate a small bowel obstruction, this finding alone does not necessarily indicate an immediate life-threatening condition. The client should be monitored, but this is not the priority.

B. Abdominal rigidity in the context of a volvulus (twisting of the bowel) can indicate bowel ischemia or perforation, which is a surgical emergency. Immediate intervention is needed to prevent further complications such as sepsis or peritonitis.

C. A paralytic ileus is a common postoperative complication and often resolves with time. While the absence of bowel sounds is concerning, it is a routine finding in this situation and does not require immediate attention unless there are signs of further complications.

D. Abdominal distention in a large bowel obstruction can indicate a need for further assessment and treatment. However, compared to a volvulus with abdominal rigidity, this situation is less urgent and does not represent an immediate life-threatening emergency.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"D"},"D":{"answers":"A"}}

Explanation

Rationale:

  • Assessment: This describes the findings relevant to the current situation, such as the elevated digoxin level (2.2 ng/mL), the client’s heart rate (79 beats/minute), and the absence of symptoms such as decreased perfusion, indicating that the client is stable for now.
  • Background: Provides necessary patient details, such as age, diagnosis (heart failure), and the fact that the client has been on digoxin for three days, so the nurse provides a brief clinical history relevant to the current issue.
  • Recommendation: The nurse suggests rechecking the digoxin level the next day to assess if it has returned to the therapeutic range. Suggests an action to the healthcare provider (recheck digoxin level tomorrow) and indicates that the nurse will monitor the client closely for any changes.
  • Situation: The nurse is holding the digoxin due to the elevated level, which exceeds the therapeutic range. This introduces the immediate reason for the call, explaining the context of the patient's condition and recent treatment.

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