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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1350"]
Explanation
Rationale:
Fluid resuscitation rate using the Parkland formula:
- Calculate the total fluid volume needed for the first 24 hours.
The Parkland formula: 4 mL × client weight (kg) × % TBSA burned.
Client weight = 90 kg
TBSA burned = 45%
Total fluid volume = 4 mL × 90 kg × 45 = 16,200 mL
- Determine the amount of fluid to be given in the first 8 hours.
According to the Parkland formula, half of the total fluid volume is administered in the first 8 hours from the time of the burn injury.
Fluid for first 8 hours = 16,200 mL / 2
= 8,100 mL
- Calculate the infusion rate for the first 8 hours.
The burn occurred at 1000. The nurse arrives at 1200. This means 2 hours have already passed since the burn occurred within the initial 8-hour period.
Remaining time in the first 8 hours = 8 hours - 2 hours
= 6 hours.
Infusion rate (mL/hour) = Fluid for remaining first 8 hours / Remaining time in first 8 hours
= 8,100 mL / 6 hours
= 1350 mL/hour.
Correct Answer is A
Explanation
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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