An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

Facilitate a consultation for speech therapy.

Arrange for daily home care assistance.

Use pictures and gestures to communicate.

Initiate passive range of motion exercises.

Answer and Explanation

The Correct Answer is A

A. Facilitate a consultation for speech therapy: Aphasia and difficulty swallowing are common after a CVA. A speech therapist can assess and provide interventions to address both speech and swallowing issues, improving communication and reducing the risk of aspiration or choking.

B. Arrange for daily home care assistance: While home care assistance may be necessary later, the immediate priority is addressing the client's communication and swallowing difficulties through therapy and clinical interventions.

C. Use pictures and gestures to communicate: This is helpful for the client’s communication, but it should be seen as an adjunct to speech therapy, not a substitute. Speech therapy provides targeted interventions to improve both speech and swallowing.

D. Initiate passive range of motion exercises: Although range of motion exercises are important for preventing joint contractures and promoting mobility, addressing the client’s swallowing and communication issues is a more immediate priority.

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Correct Answer is []

Explanation

Rationale for Correct Choices:

Nephrotic Syndrome: The child’s symptoms, including edema, fatigue, increased weight despite decreased appetite, and proteinuria, point towards nephrotic syndrome. This condition involves the loss of protein (mainly albumin) in the urine, leading to edema. The laboratory result of 2+ protein in the urine and low albumin level of 2.8 g/dL are consistent with nephrotic syndrome.
Provide a low-salt diet: A low-salt diet is a key intervention in nephrotic syndrome to help manage fluid retention and edema. Sodium causes water retention, which worsens edema, and limiting salt intake can help reduce swelling and manage the symptoms effectively.
Administer albumin: Administering albumin is important in nephrotic syndrome because it helps replenish the albumin levels in the blood. Restoring the albumin levels can help reduce edema by improving osmotic pressure and preventing fluid from accumulating in the tissues.
Daily weight: Daily weight monitoring is essential to assess for changes in fluid retention. In nephrotic syndrome, fluid retention can fluctuate, and regular monitoring helps assess the effectiveness of the treatment plan and helps guide further interventions.
Abdominal girth: Monitoring abdominal girth is necessary to track the extent of fluid accumulation in the abdomen. Abdominal edema is common in nephrotic syndrome, and significant increases in girth could indicate worsening fluid retention.

Rationale for Incorrect Choices:

Type 1 diabetes: This presents with increased thirst, frequent urination, and weight loss due to elevated blood glucose levels. However, this child is experiencing weight gain despite decreased appetite and has symptoms of edema, which are not typical of diabetes.
Wilms' tumor: Wilms' tumor presents with an abdominal mass, hematuria, or pain, which is not mentioned in this case. While renal issues could cause edema, the lab results of proteinuria and low albumin suggest nephrotic syndrome rather than a malignancy like Wilms' tumor.
Hemolytic uremic syndrome: Hemolytic uremic syndrome is characterized by hemolytic anemia, thrombocytopenia, and acute kidney injury. The child does not show signs of anemia, low platelets, or kidney failure (such as elevated creatinine), which are key features of HUS.

Place the child on strict bed rest While it’s important to monitor the child closely, strict bed rest could lead to muscle weakness and decreased mobility. The focus should be on managing edema and ensuring proper fluid balance, not restricting movement.
Prepare the child for emergency surgery: Emergency surgery is not indicated for nephrotic syndrome, which is a non-surgical condition that can be managed with medications (like albumin) and lifestyle adjustments (such as a low-salt diet).
Prepare an insulin drip: An insulin drip would be appropriate for managing hyperglycemia, typically seen in diabetic emergencies. However, this child does not show any signs of diabetes or hyperglycemia. The focus is on managing nephrotic syndrome.

Lymph node size: Lymph node size is monitored in cases of infection or malignancy. In nephrotic syndrome, the primary concern is fluid retention and protein loss, not lymph node enlargement.
Bladder volume: Bladder volume monitoring is typically relevant in cases of urinary retention or other urinary tract disorders. This child’s primary concern is proteinuria and edema, which are linked to kidney function and fluid balance, rather than bladder volume.
Ketones: Monitoring ketones is generally relevant in cases of uncontrolled diabetes or prolonged fasting. However, this child is not presenting with symptoms of hyperglycemia or ketosis. Nephrotic syndrome does not typically involve ketones.

A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting. B. Encourage family members to cook meals outdoors and bring the cooked food inside. C. Assess the client's mucous membranes and report the findings to the healthcare provider. D. Advise the client to replace cooked foods with a variety of different nutritional supplements.

Correct Answer is B

Explanation

A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting:While antiemetics can be helpful, this action may not address the underlying issue of food smells causing nausea. It is important to address the client’s sensory triggers.

B. Encourage family members to cook meals outdoors and bring the cooked food inside:
This can help reduce the trigger for nausea caused by the smell of cooking food. Cooking outdoors minimizes exposure to food smells, which could alleviate the client’s discomfort.

C. Assess the client's mucous membranes and report the findings to the healthcare provider: Assessing the mucous membranes is important in general care, especially for clients with cancer, but it is not directly related to the reported issue of nausea triggered by food smells.

D. Advise the client to replace cooked foods with a variety of different nutritional supplements: While nutritional supplements can be useful if the client is unable to tolerate solid foods, this advice doesn't address the root cause of the nausea related to food smells.

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An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

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Correct Answer is []

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