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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Alerting the family members of coworkers about possible exposure to anthrax is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The family members of coworkers are not at risk of infection, and alerting them may cause unnecessary panic and stigma.

Choice B reason: Placing the employee under quarantine for 14 days is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The employee does not need to be isolated from others, and quarantine may interfere with their access to medical care and social support.

Choice C reason: Referring coworkers who might have been exposed to a provider for prophylactic antibiotics is an action that the nurse should take. Anthrax is a serious bacterial infection that can be fatal if left untreated. The coworkers who might have been exposed to the same source of anthrax as the employee should receive prophylactic antibiotics as soon as possible to prevent the infection from developing.

Choice D reason: Instructing the employee to wear a mask at work is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The employee does not need to wear a mask at work, and doing so may cause unnecessary discomfort and discrimination.

A. Blood pressure screening B. Mental status examination C. Review of the neighborhood D. Family history

Correct Answer is C

Explanation

Choice A reason: Blood pressure screening is not the first thing that the nurse should perform, as it is a physical assessment that can be done later in the visit. Blood pressure screening is important to monitor the client's cardiovascular health and risk of hypertension, but it is not a priority for the initial visit.

Choice B reason: Mental status examination is not the first thing that the nurse should perform, as it is a psychological assessment that can be done later in the visit. Mental status examination is important to evaluate the client's cognitive, emotional, and behavioral functioning and identify any mental health issues, but it is not a priority for the initial visit.

Choice C reason: Review of the neighborhood is the first thing that the nurse should perform, as it is an environmental assessment that can provide valuable information about the client's living conditions, safety, and resources. Review of the neighborhood is important to identify any potential hazards, barriers, or needs that may affect the client's health and well-being, and to plan appropriate interventions and referrals.

Choice D reason: Family history is not the first thing that the nurse should perform, as it is a genetic and social assessment that can be done later in the visit. Family history is important to determine the client's risk of inheriting or developing certain diseases, and to understand the client's family dynamics and support system, but it is not a priority for the initial visit.

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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?

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