The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which would the nurse include in the plan? Select all that apply.•Assess for the presence of a swallow reflexPlace the food on the affected side of the mouth•Assist the client with eating•Thick...
The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which would the nurse include in the plan? Select all that apply.
•Assess for the presence of a swallow reflex
Place the food on the affected side of the mouth
•Assist the client with eating
•Thicken liquids
•Provide ample time for the client to chew and swallow
At the beginning of the work shift, the nurse assesses the status of a client wearing a halo device. The nurse determines that which assessment finding requires intervention?
a. Tightened screws
b. Red skin areas under the jacket
c. Clean and dry lamb's wool jacket lining
d. Finger-width space between the jacket and the skin
The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the primary health care provider and reports that the client is exhibiting which posture? Refer to figure.
a. Flaccid quadriplegia
b. Opisthotonos
c. Decorticate rigidity
d. Decerebrate rigidity
At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98° F (37.2° C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F (36.7° C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse would take which action first?
a. Administer an antihypertensive PRN
b. Retake the vital signs
c. Reorient the client
d. Call the primary health care provider
A 78-year old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
a. Schedule for a STAT computed tomography (CT) scan of the head
b.Notify the speech pathologist for an emergency consultation
c.Discuss the precipitating factors that caused the symptoms
d.Prepare the administer recombinant tissue plasminogen activator (rt-PA)
The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)?
a.Recording the amount of urine obtained with catheterization
b.Leaving the client in an unchilled area of the room
c.Updating the home safety sheetThis study source was downloaded by 100000859644558 from CourseHero.com on 06-16-2023 07:57:40 GMT -05:00
https://www.coursehero.com/file/190714079/MS2Quiz-9-CVA-Spinedocx/brilliantsmart d.Noting a bowel movement on the client progress note
A nurse is caring for a client following a lumbar laminectomy. Which of the following actions should the nurse take?
a.Have the client wear a cervical collar for the first 12 hr.
b.Logroll the client every 2 hr.
c.Supine with her arms elevated on pillows
d.Head of her bed elevated 30 degrees
The nurse is planning care for a client who experienced a cerebrovascular accident (CA) with residual dysphagia. The nurse knows to avoid which of the following actions in
the plan of care?
a.give food with the consistency of oatmeal
b.Feed the client slowly
c.Give the client thin liquids
d.Place food on the unaffected side of the mouth
A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What would the nurse immediately suspect?
a.Return of spinal shock
b.Impending brain attack (stroke)
c.Malignant hypertension
d.Autonomic dysreflexia
A nurse is caring for an older adult client with a history of stroke who has been prescribed several medications and expresses reluctance to take them because of his difficulty swallowing. Which of the following actions is the nurse's priority?
a.Check to see if the client's medications can be crushed and mixed with soft foods.
b.Observe for symmetry of the client's soft palate and uvula.
c.Notify the provider of the client's report.
d.Ask the pharmacist whether a liquid form of the medication can be substituted for the client.
A nurse is preparing to administer enteric-coated aspirin to an older adult client who had a cerebrovascular accident and has difficulty swallowing medications. The client asks the nurse if she will crush the medication to make it easier to swallow. Which of the following responses should the nurse make?
a."That would release all the medication at once, rather than over time."
b."I will crush it and mix it in some ice cream for you.
c."If I crush it you might experience a stomach ache or indigestion."
d."Stomach acid will inactivate some of the medication if I crush the medication."
The rehabilitation LVN is providing care for a client diagnosed with a lumbar spinal cord injury. In developing the plan of care for this client, the nurse knows to implement which of the following?
a.Perform active range of motion exercises to the lower extremities
b.Refer to a speech therapist for swallow evaluation and strategiesThis study source was downloaded by 100000859644558 from CourseHero.com on 06-16-2023 07:57:40 GMT -05:00
https://www.coursehero.com/file/190714079/MS2Quiz-9-CVA-Spinedocx/brilliantsmart
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