A home health nurse is visiting a client who had a stroke 2 months ago. Which of the following findings should the nurse report to the interprofessional care team?
The client dresses her affected side first.
The client bears weight on their arms when using crutches.
The client coughs when swallowing her medications.
The client's caregiver fills a pill organizer weekly.
The Correct Answer is C
Choice A reason: The client dressing her affected side first is not a finding that the nurse should report to the interprofessional care team, as it indicates that the client is following the proper technique for dressing after a stroke. Dressing the affected side first helps the client maintain range of motion and prevent contractures of the affected limbs.
Choice B reason: The client bearing weight on their arms when using crutches is not a finding that the nurse should report to the interprofessional care team, as it is a normal and expected way of using crutches. Bearing weight on the arms helps the client balance and support their body weight while walking with crutches.
Choice C reason: The client coughing when swallowing her medications is a finding that the nurse should report to the interprofessional care team, as it indicates that the client may have dysphagia, or difficulty swallowing, which is a common complication of stroke. Dysphagia can increase the risk of aspiration, pneumonia, dehydration, and malnutrition. The nurse should assess the client's swallowing ability and refer them to a speech-language pathologist for further evaluation and intervention.
Choice D reason: The client's caregiver filling a pill organizer weekly is not a finding that the nurse should report to the interprofessional care team, as it is a positive and helpful way of managing the client's medications. Filling a pill organizer weekly can help the client and the caregiver remember the medication names, doses, and schedules, and prevent medication errors or omissions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A child who has a BMI of 18 is not the highest priority, as it is within the normal range for children. BMI, or body mass index, is a measure of weight relative to height. A BMI of 18 is considered healthy for children aged 2 to 20 years, according to the Centers for Disease Control and Prevention (CDC). The nurse should monitor the child's growth and development and provide nutrition education as needed.
Choice B reason: An adolescent who has scoliosis is not the highest priority, as it is a common and usually mild condition. Scoliosis is a sideways curvature of the spine that affects about 3% of adolescents. Most cases of scoliosis are mild and do not require treatment, although some may need braces or surgery. The nurse should refer the adolescent to a specialist for further evaluation and management.
Choice C reason: An adolescent who has psoriasis is not the highest priority, as it is a chronic and non-contagious condition. Psoriasis is a skin disorder that causes red, scaly patches on the skin that may itch or burn. Psoriasis is not curable, but it can be controlled with medications, creams, or light therapy. The nurse should provide education and support to the adolescent and encourage them to seek medical care as needed.
Choice D reason: A child who has nits is the highest priority, as it indicates a parasitic infestation that can spread to others. Nits are the eggs of head lice, which are tiny insects that live on the scalp and feed on blood. Head lice can cause itching, irritation, and infection of the scalp. The nurse should isolate the child and notify the parents and the school staff. The nurse should also provide instructions on how to treat the infestation and prevent reinfestation.
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: You should avoid sexual contact until therapy is complete. This is to prevent the transmission of the infection to others, and to avoid reinfection or complications. The usual treatment for chlamydia is a single dose of an antibiotic, such as azithromycin or doxycycline. You should abstain from sexual activity for at least 7 days after taking the medication.
Choice B reason: Notify anyone with whom you have had sexual contact over the past 2 months. This is to inform them of their possible exposure to the infection, and to encourage them to get tested and treated if necessary. Chlamydia is a sexually transmitted infection that can cause pelvic inflammatory disease, infertility, ectopic pregnancy, and neonatal complications. It can also increase the risk of acquiring or transmitting other STIs, such as HIV.
Choice C reason: You will need to take an antiviral medication for 30 days. This is not a correct information that the nurse should include in the teaching. Chlamydia is a bacterial infection, not a viral infection. Antiviral medications are not effective against chlamydia, and are not indicated for its treatment.
Choice D reason: Once you complete treatment, you will have an acquired immunity against chlamydia. This is not a correct information that the nurse should include in the teaching. Chlamydia does not confer immunity, and you can get infected again if you are exposed to the bacteria. You should get tested for chlamydia at least once a year, or more often if you have multiple or new sexual partners.
Choice E reason: You might experience painful urination until the infection has resolved. This is a correct information that the nurse should include in the teaching. Chlamydia can cause inflammation and irritation of the urethra, which can result in dysuria, or painful or difficult urination. Other symptoms of chlamydia may include abnormal vaginal or penile discharge, lower abdominal pain, bleeding between periods, or pain during sex. However, some people may not have any symptoms, and may not know they are infected. Therefore, it is important to get tested regularly and to use condoms to prevent the spread of the infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today