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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Conducting counseling for at-risk parents is not a primary prevention strategy, as it is a secondary prevention strategy. Secondary prevention aims to stop violence from recurring after it happens, by identifying and intervening with those who are at risk of being victims or perpetrators of violence. Counseling for at-risk parents may help them cope with stress, resolve conflicts, and improve their relationships, but it does not prevent violence from happening in the first place.
Choice B reason: Assessing a family for marital discord is not a primary prevention strategy, as it is a secondary prevention strategy. Secondary prevention aims to stop violence from recurring after it happens, by identifying and intervening with those who are at risk of being victims or perpetrators of violence. Assessing a family for marital discord may help the nurse detect signs of abuse, neglect, or violence, and refer the family to appropriate services, but it does not prevent violence from happening in the first place.
Choice C reason: Teaching parenting techniques to new parents is a primary prevention strategy, as it aims to prevent violence from ever happening in the first place. Primary prevention works by addressing the underlying causes of violence, such as gender inequality, social norms, and power imbalances, and promoting positive attitudes and behaviors across the whole population. Teaching parenting techniques to new parents may help them develop skills, knowledge, and confidence to raise their children in a healthy, safe, and supportive environment, and prevent child abuse and neglect.
Choice D reason: Providing treatment for a young adult who has a substance use disorder is not a primary prevention strategy, as it is a tertiary prevention strategy. Tertiary prevention aims to respond to the long-term impacts of violence, by providing care and support to those who have experienced or perpetrated violence, and reducing the consequences and recurrence of violence. Providing treatment for a young adult who has a substance use disorder may help them recover from their addiction, improve their mental and physical health, and reduce their involvement in violence, but it does not prevent violence from happening in the first place.
Correct Answer is C
Explanation
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.
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