An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)
Place a bedside commode next to bed.
Measure neurological vital signs every 4 hours.
Suction oral cavity every 4 hours.
Encourage family to participate in the client's care.
Play classical music in room while client is
Correct Answer : A,B,D
The correct answer is a. Place a bedside commode next to bed., b. Measure neurological vital signs every 4 hours., d. Encourage family to participate in the client’s care.
Choice A rationale:
Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.
Choice B rationale:
Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.
Choice C rationale:
Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management. Routine suctioning can also cause discomfort and potential injury.
Choice D rationale:
Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process. Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.
Choice E rationale:
Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation. The effectiveness of music therapy can vary based on individual preferences.
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Related Questions
Correct Answer is D
Explanation
A) Incorrect- Observing for swelling at the fracture site is important for assessing the client's musculoskeletal condition, but it is not the priority intervention in this situation. The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest, and immediate intervention is needed.
B) Incorrect- Analyzing the cardiac rhythm in another lead is not the first priority when the client is in cardiac arrest. Cardiopulmonary resuscitation (CPR) should be initiated immediately to restore circulation.
C) Incorrect- Obtaining a 12-lead electrocardiogram is not the initial intervention in a client in cardiac arrest. CPR and defibrillation (if indicated) are the immediate actions to provide circulation and oxygenation to the vital organs.
D) Correct- The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is critical to provide circulation and oxygenation to the vital organs. Chest compressions are the initial step to address cardiac arrest and ensure blood flow to the body.
Correct Answer is A
Explanation
Tertiary prevention programs focus on minimizing the impact of an existing disease or condition and preventing further complications or disability. In the context of cardiovascular disease, one of the goals of tertiary prevention is to provide prompt rehabilitation for clients who have incurred disease complications.
By ensuring that clients who experience complications promptly receive rehabilitation services, the program is effectively addressing the needs of these clients and providing appropriate interventions to minimize the long-term impact of the disease. This outcome indicates that the program is successful in providing the necessary care and support to clients with cardiovascular disease.
Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign focuses on primary prevention rather than tertiary prevention.
At-risk clients receiving an increased number of routine health screenings may be an indicator of improved secondary prevention efforts, but it does not specifically measure the effectiveness of the tertiary prevention program for clients with cardiovascular disease.
Clients reporting new confidence in making healthy food choices is a positive outcome but does not directly reflect the effectiveness of the tertiary prevention program for cardiovascular disease.
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