A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?

Choice A Reason:

Experiences nocturia is incorrect. Nocturia (waking up at night to urinate) is a common symptom and, while it's important to address for the client's comfort and potential underlying causes, it doesn't pose an immediate risk to the client's roommate or necessitate urgent intervention in a shared room setting.

Choice B Reason:

History of generalized anxiety disorder is incorrect. A history of generalized anxiety disorder is relevant to the client's mental health and overall care. However, in the context of a shared room, it might not require immediate attention or interventions that directly impact the roommate's health or safety.

Choice C Reason:

Recent exposure to tuberculosis is correct. Tuberculosis (TB) is an infectious disease that spreads through the air when an infected person coughs or sneezes. In a shared room, a history of recent exposure to TB is a significant concern as it poses a potential risk to both the client and the roommate. Immediate measures to prevent transmission and ensure proper isolation protocols are necessary to protect the health of both individuals in the shared space.

Choice D Reason:

Reports periodic migraine headaches is correct.

Periodic migraine headaches are a health concern for the client experiencing them, but they typically do not pose an immediate risk or concern for the client's roommate. While addressing pain management is important, it might not require immediate action in the shared room environment.

Choice A Reason:

Instructing the client to tilt their head back to facilitate swallowing is not appropriate. Tilting the head back can increase the risk of aspiration (food or liquid entering the airway) for individuals with dysphagia. Instead, the client should maintain an upright position while eating.

Choice B Reason:

Encouraging the client to use a straw is inappropriate. Using a straw might increase the risk of aspiration because it can bypass the control mechanisms involved in safe swallowing, especially for someone with swallowing difficulties.

Choice C Reason:

Providing oral care before meals is correct. Providing oral care before meals helps to ensure that the client's mouth is clean, reducing the risk of infections and improving taste perception, which can enhance the client's willingness and ability to eat.

Choice D Reason:

Schedule physical therapy directly before meals is incorrect. Scheduling physical therapy directly before meals might tire the client and impact their ability to eat. Fatigue can negatively affect swallowing ability, so it's generally better to allow some rest or recovery time before meals.