A nurse is caring for a client who has dysphagia following a stroke.
When assisting the client at mealtime, which of the following actions should the nurse plan to take?

Choice A rationale

Current medication prescriptions are essential for ensuring continuity of care. Accurate documentation prevents medication errors and allows the receiving unit to administer the right medications at the correct times and dosages. It ensures the client’s therapeutic regimen continues uninterrupted and facilitates the management of conditions during the transfer process.

Choice B rationale

The primary health problem outlines the central issue requiring intensive care. This information is vital for prioritizing interventions and forming a focused care plan. It ensures the receiving team understands the client’s critical health needs and can provide the appropriate monitoring and treatment promptly.

Choice C rationale

Scheduled times for dressing changes are not typically included in transfer documentation because they represent non-urgent routine tasks. Prioritization is given to critical information like the client’s current condition and medical orders to ensure safety during the transition to the intensive care unit.

Choice D rationale

The number of family members who have visited is irrelevant to the clinical transfer process. Documentation should focus solely on medical and therapeutic information critical to the client’s ongoing care and safety, ensuring efficient communication between healthcare providers.

Choice E rationale

Admission vital signs from a week ago do not reflect the client’s current condition and are not useful for guiding care. Transfer documentation should include recent and relevant clinical data to assist the receiving team in assessing and managing the client’s immediate needs.

Choice A rationale

Using the palm of the hand is not an effective method for detecting masses. The fingertips provide better sensitivity due to their high density of sensory nerve endings, allowing for more precise identification of abnormalities such as lumps or masses.

Choice B rationale

Small circular motions allow for thorough examination of breast tissue, covering all areas including superficial and deep tissue layers. This systematic vertical pattern ensures no area is overlooked, improving detection rates for abnormalities.

Choice C rationale

Performing self-examinations during the middle of the cycle is inappropriate as hormonal fluctuations cause breast tenderness and swelling, leading to potential misinterpretation. Post-menstrual timing minimizes these effects, ensuring more accurate detection.

Choice D rationale

Lying on the side does not provide adequate support for the breast tissue, potentially limiting detection of abnormalities. Lying flat with one arm raised helps to evenly distribute and expose breast tissue for more effective palpation.