A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke.
Which of the following actions by the nurse best promotes communication among staff caring for the client?
Posting swallowing precautions at the head of the client’s bed
Noting changes in the treatment plan in the client’s medical record.
Having interdisciplinary team meetings for the client on a regular basis
Recording the client’s progress in the nurses’ notes
The Correct Answer is C
Having interdisciplinary team meetings for the client on a regular basis.
This action best promotes communication among staff caring for the client because it allows for consistent and coordinated care planning, information sharing, and goal setting for the client who has expressive aphasia and right hemiparesis following a stroke.
Choice A is wrong because posting swallowing precautions at the head of the client’s bed does not promote communication among staff, but rather informs them of the client’s risk of aspiration due to dysphagia, which is a common complication of stroke.
Choice B is wrong because noting changes in the treatment plan in the client’s medical record is a standard practice that does not necessarily enhance communication among staff, but rather documents the client’s progress and interventions.
Choice D is wrong because recording the client’s progress in the nurses’ notes is also a standard practice that does not necessarily enhance communication among staff but rather provides a summary of the client’s status and care.
Expressive aphasia is an acquired language disorder that affects the ability to produce spoken or written language, while right hemiparesis is a weakness or partial paralysis of the right side of the body.
Both of these conditions are caused by damage to the left hemisphere of the brain, which is responsible for language and motor control of the right side of the body. Stroke and traumatic brain injury are common causes of left hemisphere-damage
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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse should recognize the client is experiencing preterm labor due to previous preterm birth.
Preterm labor is when regular contractions begin to open the cervix before 37 weeks of pregnancy. One of the risk factors for preterm labor is having a previous preterm delivery. The client’s history indicates that her last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. The client’s current symptoms, such as lower back pain, pinkish vaginal discharge, uterine contractions and cervical dilation, also suggest that she is in preterm labor. Therefore, the nurse should recognize that the client is experiencing preterm labor due to previous preterm birth.
BMI, blood type and blood pressure are not causes of preterm labor in this case. BMI may be associated with preterm labor if it is too high or too low, but the client’s BMI is within the normal range for pregnancy. Blood type may cause Rh incompatibility if the mother is Rh negative and the baby is Rh positive, but the client’s blood type is Rh positive. Blood pressure may cause preeclampsia if it is too high, but the client’s blood pressure is normal. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, which can cause vaginal bleeding, abdominal pain and fetal distress. The client does not have these signs.
Correct Answer is B
Explanation
Choice A reason:
Explaining the procedure to the client before verifying informed consent is not an appropriate action: While it is essential to explain the procedure to the client and ensure they have a clear understanding of what they are consenting to, this step typically occurs before the informed consent form is presented. The purpose of the informed consent form is to document that the client has received adequate information and has given their consent voluntarily
Choice B reason:
Confirming the client's signature is authentic is the correct action. Verifying the record of informed consent for a client scheduled for surgery involves several important steps. Of these, the nurse's primary responsibility is to ensure that the client's signature on the informed consent form is authentic. This means ensuring that the client themselves or their authorized representative has signed the form willingly and without coercion.
Choice C reason:
Providing information on the informed consent form about the benefits of the surgery is not an appropriate action: The informed consent form typically contains information about the procedure, its risks, possible complications, and alternatives, but it is not the nurse's responsibility to provide this information. The healthcare provider or surgeon is responsible for explaining the details of the surgery to the client before obtaining their consent.
Choice D reason:
Informing the client about the condition that requires treatment is not an appropriate action: The responsibility of informing the client about their medical condition, the need for treatment, and the available options lies with the healthcare provider or surgeon, not the nurse. The nurse may assist in providing information or answering questions, but the primary responsibility for discussing the medical condition lies with the provider.
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