A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following interventions should the nurse include in the plan of care? 1. when the nurse performs the initial assessment, he notes that the client has received only 80 mL Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has dysphagia following a stroke. Offer the client a straw to drink liquids 2. Place food on the unaffected side of the client's mouth. Which of the following nutrional therapies should the nurse expect to include in the plan of care?, During an admission interview, the client tells the nurse that he May 1, 2023 · a. it will help the client recognize physical limitations. impulse control difficulty b. Client's blood pressure is 194/120. The nurse is caring for a hospitalized patient who has had a stroke and is waiting to be transferred to a rehabilitation facility. See Also. B. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow C. 9. " "Use a higher Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is admitting clients following an earthquake. A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. -Place the wheelchair on the client's left side when transferring him into a wheelchair. Speak to the client about one idea at a time B. Regular oral hygiene is an essential intervention for the client who has had a stroke. A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. Within 6 hours of being admitted Dec 2, 2022 · Dysphagia Impaired Swallowing Nursing Care Plan 4. The nurse stresses that it is important for the patient to be evaluated primarily because the patient has Nov 29, 2023 · A nurse planning care for a client who has had a stroke resulting in aphasia and dysphagia must carefully delegate tasks to ensure each is within the scope of practice of the assistive personnel. " 3. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which nursing action is most appropriate for communicating with the client? A. Which of the following findings should the nurse identify as an indication of short-term Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with the plan of care for a client who has a cerebral aneurysm . which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Stroke. The client will verbalize one new word each week. Which of the following goals should the nurse include int he client's rehab program? a. Study with Quizlet and memorize flashcards containing terms like The nurse has provided discharge instructions to a client with an application of a halo device. Notify the charge nurse of the transfer request, A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. pad the client's wrist before applying the restraints (rationale: the use of restraints w/o padding can abrade the client's skin, resulting in client injury) Other rationales: B>the nurse should evaluate the client's circulation, ROM, VS, and overall status every 15 min after initial application of restraints C> the nurse should remove the restraints at least q2h to reposition the client So that's it. Modifications to plan of care. The brain MRI reveals an infarct. b. The nurse determines that the client needs further teaching if which statement is made? 1. C. Which of the following nursing measures is inappropriate when providing oral hygiene? 1. left hemiplegia c. "I will drive only during the daytime. Having the client choose which clothes to wear to rehabilitation. Which of the following tasks should the nurse assign to an AP? SATA a. is the safest option c. " "Ask multiple choice questions as part of the conversation. A nurse should address these risk factors as a priority and in- stitute measures because: SELECT ALL THAT APPLY. Establish the ability to communicate effectively b. The client will begin to help turn himself in bed, indicating improved mobility. Which nursing diagnosis should the nurse include in the plan of care? A Impaired physical mobility related to right-sided hemiplegia. The task that should be assigned to an assistive personnel is: Assist the client with a partial bed bath. Which of the following are expected findings? Select all that apply. Lack of awareness, A nurse is caring for a client who has left homonymous hemianopsia A. So we're not talking about an active emergency, we're just talking about a patient who has had a stroke before. Impulse control difficulty B. Position the client's affected arm so it hangs down freely from the shoulder. Placing the client on the back with a small pillow under the head. The client is experiencing severe dysphagia with choking anfd coughing while eating. Study with Quizlet and memorize flashcards containing terms like A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore. aphasia e. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?, For an adult client, the Teach the client to scan to the right to see objects on the right side of her body B. diminished bowel sounds, a nurse is administering an otic The nurse should recognize that this route a. Study with Quizlet and memorize flashcards containing terms like A client is admitted with weakness, expressive aphasia, and right hemianopia. Aphasia is a language disorder that makes it difficult for the client to speak, understand, read, or write. The client has complete bilateral paralysis of the May 10, 2024 · Plan of care and those involved in planning. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Study with Quizlet and memorize flashcards containing terms like The nurse is planning care for a client who has a right hemispheric stroke. Which of the following readings would require calling the provider A nurse at a rehabilitation center is planning care for a client who had a left hemispheric stroke 3 weeks ago. Orient the client to the food on her plate using the clock method D. teach controlled coughing and deep breathing b. " which of the following responses should the nurse make?, A nurse is planning care for a client who has a stroke, resulting in aphasia and dysphagia. " 2. As the nurse assists with morning care, which action promotes the client’s self-esteem? Being careful not to speak of the stroke and the new deficits. The nurse understands these symptoms to be suggestive of which of the following findings?, A client is hospitalized when presenting to the emergency department with right-sided weakness. Opening the client's mouth with a padded A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. 9% sodium chloride infusing IV at 125 mL/hr. Which of the following is a nursing intervention that should be implemented during this acute phase of CVA? A) Position the client on the affected side. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?, A nurse is planning care for a client who experienced a stroke in the right Study with Quizlet and memorize flashcards containing terms like A healthcare provider orders several drugs for a client with hemorrhagic stroke. Nursing Diagnosis: Impaired Swallowing related to dysphagia secondary to stroke. A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. , The nurse is caring for an older client with receptive (sensory) aphasia. Place the client's bedside table on the right side of the bed C. " 4. Attainment or progress toward desired outcomes. Feed the client thickened liquids. Which of the following interventions should the nurse identify as the priority in the client's plan of care?, A nurse is assessing a client who recently experienced a head injury. Which of the following actions should the nurse include in the clients plan of care? 1. Which of the following actions should the nurse plan to take? Remind the client to refrain from trying to speak. Call the physical Study with Quizlet and memorize flashcards containing terms like A nurse is contributing to the plan of care of a client who has had a stroke. has the slowest absorption rate d. Loosen the client's bed linens. functional status before the stroke will help predict outcomes. 1. Apr 30, 2024 · Utilize this comprehensive nursing care plan and management guide to provide exceptional care for clients diagnosed with dysphagia or those with impairment in swallowing. Which of the following responses by the nurse is appropriate? "Incorporate nonverbal cues in the conversation. Rational A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has global aphasia. Speak to the client about one idea at a time b. Which of the following are expected findings? (select all that apply) A. What should the nurse do?-Anticipate the client will exhibit some degree of expressive or receptive aphasia. The client has weakness on the right side of the body. loss of depth perception d. B) Avoid placing the unresponsive person on the back. Loss of Depth perception D. Demonstrate the ability to initiate prompt emergency response measures, including activating the stroke code, contacting healthcare providers, and administering clot-busting medications for ischemic strokes. Dysarthria 2. Expressive aphasia 3. the rehabilitation plan will be guided by it. Client has left hemiparesis. c. A nurse is planning care for a client who has dysphagia and a new dietary prescription. Measure the client's BP after the nurse administers an antihypertensive medication. "I Study with Quizlet and memorize flashcards containing terms like A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. This is a picture of if you have a patient with a history of a stroke, who has, you know, a lot of residual defects. Client continues to be drowsy. Place the client's wheelchair on her left side, A nurse is planning care for a client who has dysphagia and has a new dietary Study with Quizlet and memorize flashcards containing terms like A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. Posts related to Cerebrovascular Accident (Stroke): 8+ Cerebrovascular Accident (Stroke) Nursing Care Plans; Drugs Affecting Coagulation Clustering nursing activities Maintaining the head and neck in midline position Maintaining the head of the bed (HOB) at 30 degrees elevation --Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral A nurse is planning care for a client who had a stroke resulting in right-sided hemiplegia earlier in the day. Offer the client the bedpan every 2 hours 3. Teach the patient what to expect at the rehabilitation facility. Ask the client to multi-task. Immobilizing the extremity in a sling D. Which of the following interventions should the nurse include in Study with Quizlet and memorize flashcards containing terms like SATA A nurse is caring for a client who has experienced a right-hemispheric stroke. com Feb 18, 2022 · Stroke patients often require monitoring by nurses who are NIHSS certified and in higher care settings such as the ICU or step-down units. ) See full list on nurseslabs. This is because stroke symptoms can change rapidly and subtly and require critical thinking and prompt intervention to prevent deterioration. Study with Quizlet and memorize flashcards containing terms like A nurse is communicating with a client who has aphasia after having a stroke. Desired Outcome: The patient will be able to regain swallowing capacity and avoid any aspiration or development of aspiration pneumonia. Which of the following should the nurse assign to an assistive personnel (AP A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following clients should the nurse recommend the provider evaluate first? A client who has a penetrating head injury and A: Teach the client to scan to the right to see objects on the right side of their body B: Place the bedside table on the right side of the bed C: Orient the client to the food on her plate using the clock method D: Place the wheelchair on the client's left side, A nurse is planning care for a client who has dysphagia and a new dietary A nurse is planning care for a client who has had stroke resulting in aphasia and dysphagia. Which characteristics are associated with this condition? Select all that apply. ) - Assist the client with a partial bed bath. Encourage the client to lie down and rest for 30 min after meals 4. This is the kind of thing we're going to look at when it comes to prioritizing care for the patient. Which of the following actions should the nurse take?, A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. Aphasia is a communication disorder that can result from a stroke, making it difficult for the client to understand language or to express themselves verbally. Improve left Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has global aphasia. 4. Dysphasia 4. Electrocardiography B. The client wants to know what other measures may help reduce CVA. calf swelling d. The nurse use simple one-step directions, rather than ask the client to multi-task. Limit questions to yes and no answers. The nurse should plan to monitor the client for which of the following early indications of increased intracranial pressure ?, A nurse is planning care for several clients and is considering the clients ' risk for stroke . bladder distention b. Which is an accurate May 1, 2023 · When planning care for a client who has had a stroke resulting in aphasia and dysphagia, the nurse must focus on communication and nutritional needs. when A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Ask the client to multi-task. C Impaired verbal communication related to speech All right guys, let's work through an example Nursing Care Plan for a patient who's had a stroke. Carotid Doppler C. Place food toward the back of the clients mouth 3. lack of situational awareness, A nurse is caring for a client who has left homonymous Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who is admitted to the hospital following a cerebrovascular accident (CVA). What nursing action can best maximize the patients rehabilitation potential while awaiting the transfer? a. A family member asks the nurse how she should communicate with the client. Which of the following interventions should the nurse take? a. . The client is aphasic. Which of the following actions should the nurse take? a. Which of the following should the nurse include in the plan of care? (Select all that apply. b. a. which of the following intervention should the nurse include in the plan? Reduce stimuli Rationale: the nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment. "I will use a straw for drinking. In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because: 1. Which of the following tasks should the nurse assign to an AP? (Select all that apply. We've put it on paper. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication. Provide bright lights in the client's room. The client has hemiplegia and occasional urinary incontinence. Placing a pillow in the axilla so the arm is away from the body B. A nurse is planning to insert a peripheral IV catheter in an older Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client following a stroke. Refer the client to the speech-language pathologist (SLP Study with Quizlet and memorize flashcards containing terms like Which is the initial diagnostic test for a stroke? A. provide a brightly lit environment c. Transcranial Doppler studies D. Study with Quizlet and memorize flashcards containing terms like A client who receives a diagnosis of right-sided stroke should be assessed for risk factors of stroke during the initial hospitalization, and measures should be instituted to lessen the client's risk. Which of the following nonpharmacological Interventions should the nurse include in the plan? A. Now specifically I'm going to work through a hypothetical patient who has a previous stroke. Doing every activity for the client, including bathing and oral care. decreased blood pressure c. Study with Quizlet and memorize flashcards containing terms like The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). increases infection rates b. decreases the client's risk for reactions, A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. A nurse is planning care for a client who has had stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel ( AP ) ? ( Select all that apply. This guide equips you with valuable insights into conducting thorough nursing assessments, implementing evidence-based interventions, establishing appropriate goals, and identifying nursing diagnoses related to dysphagia or Study with Quizlet and memorize flashcards containing terms like A nursing is caring for a client who has aphasia following a stroke. A nurse is planning care for a client who had a stroke. Focus on a single form of communication. 2. Which of the following goals should the nurse identify as the priority for this client? a. Which of the following task should the nurse assign to an AP? Select all that apply A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Learn to control impulsive behavior d. Encourage the client to have home aid personal come help with ADLS. Keep the client NPO. elevate the head of the bed 20˚ d. ) A. 48. "I will use caution because the device alters balance. The client's skin will remain intact during hospitalization. Compensate for loss of depth perception c. Which of the following interventions should the nurse use when feeding the client 1. Instruct the The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand which position is appropriate select all that apply A. What should the nurse do?, Which statement reflects nursing management of the client with expressive aphasia? and more. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse's direction to stick out his tongue? 1. So just a quick reminder of your five steps for writing a care plan. Study with Quizlet and memorize flashcards containing terms like a nurse is evaluating a client's use of a cane -which of the following actions should the nurse identify as an indication of correct use?, the nurse receives report about a client who has 0. Focus on a Study with Quizlet and memorize flashcards containing terms like A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Keep the patient on bedrest to conserve energy for rehabilitation. Study with Quizlet and memorize flashcards containing terms like a nurse is assessing a client who has required bed rest for the past month. Which of the following actions should the nurse take? A. The left hemisphere is usually dominant for language. Assist the client with a partial bed bath. Aphasia E. Client has a mild headache. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply. Assisting the client with a partial bed bath would be an appropriate task for an AP. d. The nurse should monitor for which of the following findings?, The nurse is caring for a client who has had a stroke involving the right hemisphere. Limit questions to yes and no answers D. Which drug order should the nurse question? Heparin sodium Dexamethasone Methyldopa Phenytoin, A client with CVA is prescribed medication to treat the disorder. Noncontrast computed tomography, After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Keeping portable suctioning equipment at the bedside. Left hemiplegia C. Monitoring and Documenting Neurological Recovery. Massage the client's sacrum. Have suction equipment available for use. Response to interventions, teaching, and actions performed. Which of the following alterations in function should the nurse expect?, A nurse is teaching Oct 7, 2023 · When considering the tasks a nurse can assign to assistive personnel (AP) for a client who has had a stroke leading to aphasia and dysphagia the following tasks can be safely assigned: 1) assist the client with a partial bed bath, 4) using a communication board to ask what the client wants for lunch and 5) irrigate the client's indwelling Study with Quizlet and memorize flashcards containing terms like Assessing client that has been on bedrest for a month what is an indication that the client has developed thrombophlebitis?, A nurse is administering an otic medication to an older adult client. encourage a minimum intake of 2000 mL of clear fluids per day, A nurse is caring for a Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has experienced a right-hemispheric stroke. , A nurse is caring for a client who has had a A nurse is planning care for a client who had a stroke resulting in right-sided hemiplegia earlier in the day. Offer to play A. Receptive aphasia, A patient arrives at Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has increased ICP. 3. - Measure the client's BP after the nurse administers an antihypertensive medication. B Risk for injury related to denial of deficits and impulsiveness. one of every A nurse is planning care for a client who had a stroke. Ambulate the client to the bathroom every 30 minutes 2. C) Lower the Jul 31, 2024 · Study with Quizlet and memorize flashcards containing terms like The nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which action should the nurse take?, A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. Positioning a hand cone in the hand so A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. D. Teaching plan. wnicgm igkin gjz zpxu fxdhxq npx jblys znql cpzui rdgxa