A nurse is performing a home safety assessment for a client who had a stroke

A nurse is performing a home safety assessment for a client who had a stroke. The UAP should lower the side rail closest to themselves and keep the opposite rail up. The first step in caring for a client who has had a stroke is a history and physical assessment. Difficulty with concept Study with Quizlet and memorize flashcards containing terms like A nurse is performing an admission assessment for an older adult client. The nurse attributes the decreased Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who had a hemorrhagic stroke. Working around high voltage equipment 4. Explanation: If a nurse is performing a home safety assessment for a client who had a stroke and notes that the stairs pose a safety risk, and the client states that they cannot afford to have the stairs repaired, the Study with Quizlet and memorize flashcards containing terms like A client who is 8 weeks pregnant reports morning sickness. The client's skin and clothing are dirty. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. Full-thickness skin loss 3. throw rugs The nurse is discharging home a client who had a stroke. " b. Which of the following actions should the nurse perform to promote the client's safety? a. instruct the The nurse is reviewing interventions aimed at maintaining cerebral perfusion in a client who had a thrombotic stroke. The patient is unable to smell any of the odors. Costs of the visits Study with Quizlet and memorize flashcards containing terms like Structure indicators: reflect the setting in which care is provided and the available human and resource materials, QUALITY IMPROVEMENT AND PATIENT SAFETY A nurse is teaching a class about quality improvement tools. Taking a shower or bath 2. Stroke is one of the leading causes for disability in adults. Check the client's exposure to adverse elements. Which of the following would be most likely? The nurse is performing a musculoskeletal assessment of a patient in a nursing home who had a stroke 2 years ago and who has right-sided hemiplegia. Which intervention should the nurse question? A. The client is dehydrated from multiple episodes of diarrhea. Develop a plan of care. Turn the phone and radio off. " The trochlear nerve (IV) is responsible Study with Quizlet and memorize flashcards containing terms like The nurse in a health care clinic is preparing to test a client for accommodation. Intact skin 2. Which of the following terms will the nurse use to document this Study with Quizlet and memorize flashcards containing terms like A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. The correct answer is C, The client's bedside lamp is plunged in using an extension cord with two prongs. Which approach should the nurse use for this situation?, The nurse is coordinating the care for a client recovering from a stroke. The physician performs swallowing screening during a regular medical evaluation and requests that the SLP conduct further swallowing assessment Study with Quizlet and memorize flashcards containing terms like A nurse who is considering the possibility of becoming involved in home care asks a home care nurse about the characteristics needed for this practice area. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Electric cords behind the furniture C. The nurse should perform a vision field assessment to evaluate the client forhemianopia. ) Who had a hip replacement 2 months ago, The nurse is performing a Study with Quizlet and memorize flashcards containing terms like The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Tapping the Achilles tendon using the reflex hammer 2. Which UAP statement requires immediate nursing intervention?, A client has been discharged from the hospital after being treated for a myocardial infarction. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. The nurse notes that the girth of the patient's right calf is 2 inches less in Study with Quizlet and memorize flashcards containing terms like the clinical nurse is performing an assessment for a client who is complaining of shortness of breath. , The nurse is preparing to The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the Study with Quizlet and memorize flashcards containing terms like To evaluate a client's cerebellar function, a nurse should ask:, During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. Where should the nurse place the stethoscope to hear the first heart sound Study with Quizlet and memorize flashcards containing terms like The nurse is performing her morning assessment when the client says, "I had trouble sleeping last night. Best verbal Study with Quizlet and memorize flashcards containing terms like Which description of an acute embolic stroke given by the nurse is most accurate? A blood clot lodges in a cerebral vessel and blocks blood flow. , The nurse is caring for a very active, athletic adolescent recently diagnosed with multiple sclerosis. The nurse has just assisted a client back to bed after a fall. orient the client to his room. " Which action should the nurse take first?, A client is admitted to the health care facility with active tuberculosis (TB). Which of the following actions should the nurse take to assess the client's safety risk? Select all that Study with Quizlet and memorize flashcards containing terms like A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. To deselect a finding, click on the finding again. Limited knowledge exists regarding the availability of specialized education and training programs specifically designed for nurses caring for stroke Study with Quizlet and memorize flashcards containing terms like A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. Client maintains safety; breathing quiet, denies dyspnea. Create. Monitor for >50 mL/hr urine output 3. provide an obstacle free path for ambulation d. Which of the following data should the nurse include, A nurse manager finds that there has been an increase in urinary tract infections on the unit. 4- Position the client flat for at least 3 hours. Study with Quizlet and memorize flashcards containing terms like A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. A client who has a fractured leg following a vehicle crash A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client has been asked to evaluate the care Final answer: The nurse should refer the client to a social worker who can help connect them with resources for home repairs. Mississauga, Ontario Facilitating successful care transitions across settings is a key nursing competency. Review medical prescriptions. A 42-year-old client who awoke from sleep with a After stroke, occupational therapists work to facilitate and improve motor control and hand function in the stroke-affected upper limb; to maximize the person's ability to undertake his or her own personal self-care tasks and domestic tasks; to help the patient learn strategies to manage the cognitive, perceptual, and behavioral changes associated with stroke; Nursing staff performs swallowing screenings and refers patients with swallowing problems to an SLP for a comprehensive swallowing assessment. Study with Quizlet and memorize flashcards containing terms like The practical nurse (PN) is reviewing the plan of care for a client scheduled for a surgical amputation of the left lower leg. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse checks for proprioception using which assessment technique? 1 Tapping the Achilles tendon using the reflex hammer 2 Gently pricking the client's skin on the dorsum of the foot in two places 3 Firmly stroking the lateral sole of the foot and The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. bathtub with rails B. Unilateral neglect after stroke is a sign that the temporo-parietal junction and the posterior parietal cortex are most likely damaged. , A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Exposed bone, tendon, or Study with Quizlet and memorize flashcards containing terms like A nursing is caring for a client who has aphasia following a stroke. On the basis of this finding, which action is most appropriate?, The nurse performs a physical assessment on a client and gathers both subjective and A nurse is performing blood pressure screenings. What should the nurse do while providing The subacute and long-term assessment and management of patients who have suffered a stroke includes physical therapy and testing to determine the precise etiology of the event so as to prevent recurrence. Uncaps the spike portion of the A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. Frontal lobe and optic nerve tracts damage 4. ” To facilitate Which element would the nurse include in this assessment? Select all that apply. Speak in a clear and Study with Quizlet and memorize flashcards containing terms like A nurse case manager is developing a critical pathway for clients who have pneumonia. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. The patient cannot respond to objects presented to the side of a brain opposite to a side affected by 1- Administer antihistamines to the client. Previous health status c. "Some of the blood clots may have gone to your Study with Quizlet and memorize flashcards containing terms like A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Which client is a candidate for thrombolytic therapy? 1. Which of the following clients should the nurse see first? a. Check the client's ventilation E. Study with Quizlet and memorize flashcards containing terms like A nurse is performing an admission assessment for an older adult client. Redness noted at wound borders, Why measure functional outcomes in stroke trials? Large-scale clinical trials have created a robust evidence base to inform much of what is now standard acute-stroke practice. Find tips on how to bathe or shower, including tips for adaptive aid devices, bathroom transfers and more. Which of the following findings indicates an understanding of home safety? a) an extension cord is secured under a rug b) the edges of stairs are marked with brightly colored tape c) a Study with Quizlet and memorise flashcards containing terms like The nurse plans care for a client who has had a stroke and is experiencing residual expressive aphasia. Take Quiz. Which assessment should the nurse make to evaluate if a complication from the mannitol is occuring? #70666278 (20) 1. 14 terms. 7%) were females. A 38-year-old client reporting dizziness, blurred vision, and left-sided weakness for the past 5 hr 2. Disassociation Signs of unilateral neglect in a client with a recent stroke should prompt the nurse to refer to an occupational therapist. This review provides a systematic approach for identifying the relevant Be patient: Allow the person to do or say things in their own time and in their own way. The client has a flaccid right arm and leg and is experiencing urinary incontinence . Introduction. Which action should the nurse take to ensure safety for both the client and the nurse? 1. Study with Quizlet and memorize flashcards containing terms like A nurse is performing a community assessment and discovers the need for interventions to address tertiary prevention of mental health issues. That means that if you had, for example, a right MCA stroke - you would see Left sided facial drooping and left arm weakness. Keep the bedside table at the end of the client's bed 2. A nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. Conducting a comprehensive predischarge nursing assessment of caregiver physical and A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. " A home health nurse is performing an assessment of a client's skin. ASSESSMENT OF COMMUNICATION IMPAIRMENT • By means of interview, conversation, observation, standardized tests and/or non-standardized items, the communication assessment should: Stroke rehabilitation has been defined as a dynamic, goal-oriented process that aims to enable patients to achieve optimal physical, emotional, behavioral, and cognitive functioning. The nurse should include that which of the following tools is Study with Quizlet and memorize flashcards containing terms like A client is admitted with weakness, expressive aphasia, and right hemianopia. Give them time and space to practice speech, movement, or other skills. Therefore, early and effective rehabilitation training is an important In this section you will find information on the following areas that pertain to safety after a brain injury. Conduct a client care conference. 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 Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with conducting a home hazard assessment for a client who has dementia. 9 Caregivers need open and honest communication about their role and stroke survivors’ abilities, 3,10 while also offering hope. Abuse and Neglect. Performing daily exercises 3. On assessment, the client is unable to understand the nurse's commands. , 2001) for home safety assessment. A collaborative interdisciplinary team Study with Quizlet and memorize flashcards containing terms like 1. Initially, the nurse should ask the client to take which action?, The nurse is assessing a client with a history of cardiac problems. Review Study with Quizlet and memorize flashcards containing terms like Which of the following areas should the technique of palpation be used as part of the assessment?, A nurse is performing a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse completes the health history. A client arrives at the emergency department after falling in the home. B. Remove the safety pin from the extinguisher. Which of the following conditions Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. A nurse is admitting a client who has had a stroke. Based on the assessment data, the major nursing diagnoses for a patient with stroke may include the following: Impaired physical mobility The use of stroke assessment tools by nurses is necessary for regular evaluation of the patient with stroke during acute inpatient care. Therefore, early nursing care is essential, using A nurse is performing a home safety assessment for an 87-year-old retired farmer who lives alone. Check airway patency. A client had an embolic stroke and is having an echocardiogram. Confusion B. A nurse is caring for a client who is acidotic. "Daylight savings is the time to change batteries on the Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who has a cerebral artery aneurysm. Placing the client in a side-lying position B. The client identifies the location of a fire extinguisher. . Additionally, keep in mind that they Study with Quizlet and memorize flashcards containing terms like 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 findings should the nurse identify as a safety risk for the client? (Select all that apply) A. "Most of these types of blood clots come from the heart. A. Which identifies the accurate procedure for this visual acuity test?, The emergency department nurse is performing an assessment on a child suspected of being sexually abused. -Side rails have not been found to be effective in keeping a client in bed and may actually lead to injury-Maintaining a patient on bed rest can lead to deconditioning and actually contribute to falls-Assessing the client's dietary intake of Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. This deficit is related to cranial nerve (CN) X, the vagus nerve. A nurse is performing a primary survey for a client who has a life-threating condition. Which of the following referrals should the nurse make for the caregiver?, When admitting a client to the A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following should the nurse include in the teaching?, nurse is performing a follow-up visit for a client who has a G-tube through which they receive intermittent feedings and Study with Quizlet and memorize flashcards containing terms like A patient has had an ischemic stroke and has been admitted to the medical unit. washing the skin with soap and water prior to shaving B. Which of the following observations should the nurse identify as proper safety protocol? Nurse is planning care for a client who had a stroke. Correct: The nurse needs to intervene in these situations. To address this problem, the first action the nurse manager Nearly 20% of all patients with ischemic stroke will require care in an intensive care unit (ICU), particularly those who have received intravenous alteplase or endovascular therapy. ) With a history of myocardial infarction b. adult client who has been hospitalized due to a stroke is about to be discharged from a rehabilitation center where the client had to relearn how to perform Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is recovering from a stroke and has right- sided homonymous hemianopsia. The grip should be at the client's waist. Let’s Talk About Living at Home After Stroke; Stroke Family Warmline: 1-888-4-STROKE or 1-888-478-7653 Monday-Friday: 8:30 a. This 68 y/o patient with a history of hypertension develops a sudden onset of slurred speech while watching television in her Use this nursing care plan and management guide to help care for patients with cerebrovascular accident (CVA). The local cerebral tissue becomes engorged with The client has increased intracranial pressure with cerebral edema, and mannitol is administered. This deficit is related to which of the following cranial nerves? What safety actions does the nurse need to take for a client Unfortunately, stroke remains a leading cause of long-term disability in the United States. Teach about preventing hypoglycemia. Wash eyes with water only since soap is very irritating to Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. 4. Which of the following findings are a safety hazards for them? Addressing these hazards is crucial to creating a safe living environment for a client who has had a stroke. C) A patient has had an ischemic stroke and has been admitted to the medical unit. The nurse is aware that the patient has a dysfunction of which cranial nerve? a. A nurse is caring for an older client who has had a hemorrhagic stroke. Place a towel not he client's bathroom floor 3. The nursing assistant has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. The National Institutes Several tests are available when performing a neurological assessment; the tests included in the assessment are selected based on the patient’s medical condition and the neurological symptoms they are experiencing. Which of the following findings are a safety hazards for the client? A. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray? A. , The nurse is preparing to administer a medication through a The National Institutes of Health Stroke Scale (NIHSS) is the primary stroke assessment scale. Which expected outcome should the nurse include in the care plan? The client will verbalize plans for rehabilitation. C) Study with Quizlet and memorize flashcards containing terms like A nurse at a rehabilitation facility is assisting with the admission of a client who has left hemiplegia following a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. Client's symptoms occurred slowly over several hours. Which Study with Quizlet and memorize flashcards containing terms like A client recovering from a stroke has slid down in bed and needs to be repositioned. The nurse and health care provider have assessed the client and have determined A nurse is performing a home safety assessment for a client who had a stroke. We will see the weakness and deficits present contralateral to the stroke. rinsing the razor after each stroke of the razor D. On the basis of these assessment findings, the nurse should make which interpretation? a. The history includes interviewing the Ineffective Cerebral Tissue Perfusion Assessment. Which condition should the nurse document? 1. )formation of new A healthcare professional is conducting a risk evaluation for a patient who suffered a cerebral event. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. Study with Quizlet and memorize flashcards containing terms like The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. About what drug would the nurse plan to teach the patient? a. Following RACE, the first step the nurse should take is to rescue, or assist the residents out of the room to safety. A nurse is performing a home safety assessment for a client who had a stroke. The professional observes that the vertical access points in the patient's residence are not in good condition and could potentially be hazardous. Raise the head of the bed before repositioning. Which of the following actions should the nurse take first?, A nurse is planning care for a client who practices Judaism. The client is being discharged home with a referral for home health care. Auscultate breath sounds to assess for crackles 2. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. The nurse is performing an assessment on a client with a diagnosis of thrombotic brain attack (stroke). A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. Monae_Ortiz. What should the nurse tell the client to avoid while monitoring is in progress? Select all that apply 1. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit? 1. Keep the client's bed in the lowest position Background Stroke survivors have complex needs that necessitate the expertise and skill of well-trained healthcare professionals to provide effective rehabilitation and long-term support. The nurse is caring for a client with chronic migraines who is prescribed medication. This deficit is related to cranial nerve (CN) X, the vagus Study with Quizlet and memorize flashcards containing terms like The nurse is performing a musculoskeletal assessment of a patient in a nursing home who had a stroke 2 years ago and who has right-sided hemiplegia. Which of the following statements Study with Quizlet and memorize flashcards containing terms like A student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale. Which of the following actions should the nurse take? A) Assign the client to a private room B) A nurse is performing a neurological assessment of a client. Greetings from Doris Grinspun Nurses providing direct client care will benefit from reviewing the Paramed Home Health Care. Check the client's level of consciousness B. Determine baseline presentation. The nurse should include which intervention in the plan of care?, A Provide ample time for the client to chew and swallow, The nurse is caring for a client with a diagnosis of right (non-dominant) hemispheric stroke. See an expert-written answer! We have an expert-written solution to this Pain level stabilized at client goal b. Which of the following comments by the patient would indicate a need for further education? a. "I will schedule an appointment with a chimney inspector next week. The nurse checks for proprioception using which assessment technique? 1. Which of the following actions should the nurse plan to take?, A Another inpatient rehabilitation setting is the skilled nursing facility, an institution or a distinct part of an institution in which the primary focus is the provision of either rehabilitation services or skilled nursing care and related services to residents requiring medical or nursing care. Conduct a client care conference C. The nurse notes that the girth of the patient's right calf is 2 inches less in diameter than the left calf. The client uses a wool blanket on their bed. Then we often see aphasia, which means lack of speech or trouble with speaking. Which of the following findings should the nurse address?, A nurse is performing an eye assessment of an older adult client and identifies a corneal ulceration. " Which response would the nurse make? 1 "Did you forget to take your A nurse is educating an older adult client about home safety. raised toilet seats D. A nurse massages the back of a client while performing a skin assessment. Check the client's circulation caregiver to meet the care needs of the stroke survivor; the likelihood of returning to community living; and the ability to participate in rehabilitation. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to Having a stroke can affect your hygiene routine. 45% sodium chloride. The nurse should identify that the client is unable to perform which of the following tasks? - Sit on the edge of the bed for 1 min - Stand in place for 5 seconds - Walk in place - Step forward and backward Study with Quizlet and memorize flashcards containing terms like Which assessment finding indicates that a client has had a stroke? Select all that apply Lopsided smile Unilateral vision Incoherent speech Unable to raise right arm Symptoms started 2 hours ago, Which behavior would the nurse include when teaching a family what to expect A nurse is performing an admission assessment for an older adult client. In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. 5,6 The Future of Nursing 2020 to 2030: Charting a Path to Achieve Health Equity 7 highlights the importance of the nurse’s role on the health care team in performing care management, care coordination, and transitional care to decrease Preparing to Care for a Stroke Survivor at Home. The child is the client's sole caregiver and reports feeling fatigued and overwhelmed. Ensuring cost-effective care B. Currently the client's neurologic examination is normal. Client newly 6. , A home health nurse is conducting a home safety assessment for an older adult client. nonurgent approach to client care, the nurse determines that the priority finding is a client who has a femur fracture and reports feeling short of breath. Which of the following actions should the nurse take? (Select all that apply. Post navigation. Disassociation A nurse is performing a home safety assessment for a client who had a stroke. tslackwp. The client has a nurse is performing a home safety assessment for a client who had a stroke. 2. ) A. Had a very mild stroke b. 1 Consequently, stroke survivors are often deconditioned and predisposed to a sedentary lifestyle that limits performance of activities of daily living, increases the risk for falls, and may contribute to a heightened risk for recurrent stroke and cardiovascular Study with Quizlet and memorize flashcards containing terms like A nurse is assessing an older adult client following a head injury with loss of consciousness. For what complication is the client at risk? Embolic stroke Brain cancer Hemorrhagic stroke Traumatic brain injury, A client hospitalized for hypertension presses the call light and reports "feeling funny. Home Function Resources: Home Modification video and General Home Safety A nurse has received changed-of-shift report on a group of four clients. Uncertainty C. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? a) "I swim three times a week. Assess Study with Quizlet and memorize flashcards containing terms like 1 2 1. Which of the following pieces of information in the client's medical record should the nurse identify as a risk for tinnitus?, A nurse is assessing a client who reports an acute visual disturbance that he Residential home STROKE SIMULATION SCENARIOS SCENARIO 1: Suspected Ischemic Stroke without Large Vessel Occlusion A sixty-eight year-old female patient has a sudden onset of left-sided weakness and slurred speech. A nurse is caring for a client who had a stroke and is at risk of falling. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. The nurse checks the residual and obtains an amount of 200 mL. In the earliest stages of the stroke diagnosis, nurses play a critical role in the triage of patients with acute stroke onset as well as initial assessment and timely transition within the healthcare system offering stroke care. Damage to the auditory association areas 3. After a TIA, a patient is prescribed a beta blocker. Nearly half of the sample (47; 35. What action should the nurse perform to best prevent joint deformities? The nurse is discharging home a patient who suffered a stroke. What is the most appropriate response bu the nurse?, the nurse admits an 80 y/o client with ALOC and left sided weakness following a recent stroke. 32 Similarly, after discharge to the home, nurses and CHWs offer critical support to stroke survivors and their Study with Quizlet and memorize flashcards containing terms like The nurse encourages a stroke victim by telling them that following a cerebrovascular accident (CVA) caused by thrombosis, the client's condition may improve after several days as a result of a. A client who is scheduled for physical therapy and rates his pain as a 6 on a scale of 0 to 10 c. Safety A nurse is performing a home safety assessment for a client who has experienced a stroke. A nurse is performing a neurologic assessment on a client. The nurse asks the charge nurse why the client is breathing rapidly. Preview. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image ? A. The nurse note the stars in the client's home are in disrepair and pose a safety A neurological exam is performed to ascertain stroke location, establish baseline function upon hospital admission, rule out a transient ischemic attack (TIA) and other stroke mimickers, and deduce Statement Highlights: Three scientific statements provide newer, evidence-based suggestions for practices and assessment tools that offer guidance for nurses to provide comprehensive care for patients A nurse is performing a home safety assessment for a client who had a stroke. Third, the nurse should confine the fire by closing A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Step-by-step explanation. D. the nurse identifies the client may be experiencing a stroke. Advocate for funding to support local rehabilitation services. A nurse is assessing a client who is postoperative following a transurethral The nurse is caring for a client diagnosed with an ischemic stroke and knows that the effective positioning for the client is important. Which of the following would the home care nurse be least likely to include? Nonjudgmental attitude Need for control Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who requires a wheelchair. Which of the following statements should the nurse identify as an indication that the client understands the instructions? Comprehensive Physical Examination Systematic Assessment Part II. The client is trying to get rid of excess body acids. Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to interview an older adult patient to obtain a history and physical. Even before a stroke survivor returns home, family members can take a number of steps to prepare for their arrival and care. During hospitalization, nurses are generally the first to recognize possible symptoms of stroke and activate emergency protocols. d. 3- Assess the level of consciousness (LOC) and the pupil response of the client. ) Who has to climb up a flight of stairs to get to the bathroom d. The nurse performing the assessment notes the presence of pediculosis corpus. Alteplase b. It is necessary to use the nursing process and neurological assessment scales to facilitate nursing care planning for stroke patients [1,2]. Begin processes to obtain a wheelchair. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by Study with Quizlet and memorize flashcards containing terms like The nurse navigator is coordinating the transition from the hospital to a rehabilitation facility of a client who had a total hip replacement. The client Nursing Diagnosis. 5/325 tablet PO RATIONALE A client who rates his pain as 8 on a scale of 0 to 10 is experiencing severe pain, and the nurse should administer an opioid for this type of pain. The nurse should identify that this finding can indicate which of the The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. A C. The client admits to smoking 1 pack of cigarettes per day for the past 10 years. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1. The acute management differs. The brain MRI reveals an infarct. Roll the client side to side. Solved by AI. The nurse notes that the stairs in the client's home are in disrepair and pose a safety risk. 4 Study with Quizlet and memorize flashcards containing terms like Which statement about transient ischemic at- tack (TM) is accurate? a. conduct a client care Study with Quizlet and memorize flashcards containing terms like Nurse is teaching a client and his family how to care for the client's tracheostomy at home. Shaping the future of Nursing Stroke Assessment Across the Continuum of Care June 2005. Be respectful: Treat the person as Study with Quizlet and memorize flashcards containing terms like A client has a prescription to receive 1000 mL of 5% dextrose in 0. Which comment by the patient will cause the nurse to follow up?, The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse notes that the client is alert and oriented to time and place. Answers: B & E Answer B indicates a need for additional teaching as the client is taught to dress the weaker side before the stronger side of the body when unilateral weakness occurs due to a stroke. Symptoms of a TIA usually resolve in 10- 15 minutes. On assessment, the nurse notes that the client's wound has eviscerated. limit seizure precautions b. , & 2. This chapter will focus on how the nursing assistant promotes client functioning and independence through rehabilitation and restorative care. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that The nurse is performing a neurological assessment on a client who had a stroke (brain attack). applying direct pressure to an area that Answer: A Completing a fall assessment will enable the nurse to identify and correct the risk factors for this patient. pulling the razor against the direction of hair growth C. Which of the following nursing measures is inappropriate when providing oral hygiene? A: Placing client on back with small pillow under the head B: Keeping portable suctioning equipment at the bedside C: Study with Quizlet and memorize flashcards containing terms like The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Obtain a CT scan or MRI of the brain. Which type of data is most important to a home health nurse who is performing a comprehensive assessment for a new client recently discharged from the hospital? Subjective data about how Study with Quizlet and memorize flashcards containing terms like The nurse realizes that the patient at the highest risk of falls is the patient: a. The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The staff nurse reviews the nursing documentation in a client's chart and notes that the would care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Answer E Study with Quizlet and memorize flashcards containing terms like The nurse knows that which interventions could be implemented for a stroke client at risk for aspiration? Select all that apply. Which statement best explains the standard of care being implemented? Stroke Assessment. m. What will the nurse consider a priority nursing diagnosis?, Which finding is considered a positive finding of the Romberg test?, Study with Quizlet and memorize flashcards containing terms like A nurse is organizing interprofessional team members to meet the needs of a client. Cerebral vascular pressure exceeds the elasticity of the vessel wall, resulting in hemorrhages. the client states, "I cannot afford to have the stairs repaired. Which of the following actions should the nurse take. Such actions in Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which strategy(ies) does the nurse include about how the spouse can maintain proper body mechanics and prevent injury to oneself? A nurse is conducting a home assessment of a 90-year-old client with a history of several minor Study with Quizlet and memorize flashcards containing terms like A nurse is assisting with conducting a home hazard assessment for a client who has dementia. which of the following observations should the nurse identify as Answer & Explanation. c. Answer & Explanation. Eye opening 2. Which of the following roles is the nurse taking?, Click to highlight the findings that require follow-up. Which of the following findings indicates an understanding of home safety? a) an extension cord is secured under a rug b) the edges of stairs are marked with brightly colored tape c) a This client is admitted walking and is here for a cardiac workup; the client is assigned to the nurse. Which medication therapy requires follow-up? Thiazide diuretic Anticoagulant Antiplatelet Beta blocker, Which description of an acute embolic stroke A client has had a total knee replacement and will need to walk with crutches for six weeks. The rapid respirations cause Stroke Assessment. A nurse helps a client in hospice fill out a living will form. " Which of the following actions should A nurse is performing a home safety assessment for a client who has experienced a stroke. This Study with Quizlet and memorize flashcards containing terms like a nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. The nurse is testing a client for carpal tunnel syndrome. What would the nurse expect to find in the client?, Which methods can be used to remove a client's soft contact lenses?, A nurse is assisting a client to shave his beard. Wound bed is red. 1 In Ontario, direct rehabilitation costs, nursing worked hours, and nursing plus therapy worked hours have been used (as indicators) to measure the The nurse is performing a functional assessment on an 82-year-old patient with a recent stroke. To determine where they are experiencing their symptoms. 7%) had a bachelor’s degree in nursing, whereas 105 (80. Which of the following should be integrated into the clients plan of care? a)The clients hip joint should be maintained in a flexed position b)The client should be in a supine position unless ambulating c)The client should be Study with Quizlet and memorize flashcards containing terms like A nurse is submitting a dietary request for a client who devoutly follows Mormon dietary practices. A family member asks the nurse how she should communicate with the client. )formation of new Study with Quizlet and memorize flashcards containing terms like The nurse assists with the care of several clients presenting with stroke symptoms. Client newly admitted for an evolving ischemic stroke. Heart sounds are normal. Study with Quizlet and memorize flashcards containing terms like A client is admitted to the hospital with a tonic-clonic seizure after his seizures had been well controlled by phenytoin for 6 months. Which of the following questions would be most important to ask? When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Encouraging active range-of-motion exercises C. For a specific example of this model, see Steele (2002). The nurse is performing frequent neurologic assessments and observes that the client is becoming progressively more drowsy over Empirical literature also indicates that caregivers feel uncertain and unprepared in the caregiving role. Which of the following observations should the nurse identify as proper safety protocol? The client uses a wool blanket on their bed, The client identifies the location of a fire extinguisher, The client stores an extra oxygen tank on its side The National Institutes of Health Stroke Scale (NHISS), considered the Gold Standard Acute Stroke Assessment, is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. Which of the following actions is the nurse's priority?, A nurse is caring for a client who had a right Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has an impairment of Cranial Nerve II. Prioritizing nursing intervention and intensive care monitoring can improve patient outcomes and reduce disability. Occipital lobe impairment 2. the nurse notes that the stairs in the client's home are in disrepair and pose a safety risk. Answered by TutorKK5. 1 – 3 The classical clinical trial is designed to test efficacy of a particular intervention over a comparator, for example, placebo or “usual care. Which of the following findings are a safety hazards for the client? Select all that apply. C. The priority nursing action is to: A second objective is to describe the utility and therapeutic benefit of the SAFER Tool (Chiu et al. Orleans, Ontario Janice Cicoria, RN, BScN, CNN(c) Clinical Educator, Trillium Health Centre. , A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which piece of equipment impedes circulation to the area it's meant to protect?, For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?, A female client reports to a nurse that she . Study with Quizlet and memorize flashcards containing terms like A home health nurse is performing a home assessment for safety. " b) "I have stopped smoking cigars. The client will Study with Quizlet and memorize flashcards containing terms like The nurse encourages a stroke victim by telling them that following a cerebrovascular accident (CVA) caused by thrombosis, the client's condition may improve after several days as a result of a. water heater temperature 130F E. Orient the client to their room. The scope for functional recovery is greatest during the first few months (Kwakkel et al. Which of the following interventions should the nurse implement? A. " "Ask multiple choice The nurse is observing a student who is using a safety razor to shave a client. blood pressure reading looking for hypertension B. These frequent assessments monitor LOC, visual changes, facial movement, motor coordination, sensory changes, and speech or language deficits. TIAs do not cause permanent brain damage. I didn't think I was going to have more seizures. The nurse determines that the client has a smoking history of how many packs-years?, the nurse The nurse assesses a client who is diagnosed with a stroke (brain attack). The professional observes that Helpful. The nurse must be aware that the client is likely to be confused when being evaluated, especially in the early phases of recovery. Which interventions 1. 1 There is robust evidence demonstrating significant reductions in death and disability with early interventions in acute stroke care, including antiplatelet therapy 2 stroke unit (SU) care 3 and thrombolysis. What will the home care nurse need to assess during the initial assessment? a. The client tells the nurse that he is experiencing a burning pain as a result. Table of TIA symptoms lasting less than a minute, The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. ) who uses a cane to ambulate c. Home Access and Safety and Safety Checklist Worksheet. 3. care for a client who has been admitted with a hemorrhagic stroke. This home safety intervention was part of a funded interdisciplinary randomized controlled trial known as CAReS that enrolled 159 stroke survivors and their spousal caregivers over a 5-year Which action by the nurse best represents the evaluative portion of the nursing process? determining that a client is at risk for a fall while in the hospital assessing a client's blood pressure after teaching stress reduction techniques assessing a client's blood pressure after giving a cup of coffee educating a client on how to take one's own Study with Quizlet and memorize flashcards containing terms like The care coordinator is planning actions to overcome a client 's knowledge deficit related to the use of a sleep apnea machine at home. gag reflex assessing for problems with chewing and A client who has had bowel surgery, particularly an older client, would require much assistance in performing activities of daily living while recovering. Which of the following interventions is the nurse's priority?, A nurse is caring for a client who has viral meningitis. Place the client's cane on their weaker side. b. What action should the nurse perform to best prevent joint deformities? A) Place the patient in the prone position for 30 minutes/day. Client because increasingly lethargic and drowsy. How would the nurse interpret this information?, The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. Which statement best explains the standard of care being implemented?, Which description depicts the role of the nurse practitioner?, The nurse is caring for a client after a stroke rendered the client's right side weaker than a nurse is caring for a client who had a stroke and reports having difficulty with proprioception. When assessing for a possible stroke it is vital to know the last time the Question: FLAG A nurse is performing a home safety assessment for a client who had a stroke. -Maintain the head of Study with Quizlet and memorize flashcards containing terms like A home health nurse is interviewing the adult child of a client who has Alzheimer's disease. Which of the following questions should the nurse ask the Study with Quizlet and memorize flashcards containing terms like The nurse conducts a home safety assessment for a client. Firmly stroking the lateral sole of the foot and Introduction. Which statement best explains the standard of care being implemented? The registered nurse is performing a A nurse is providing care for a client recovering from a stroke and teaches the spouse about caring for the client. Which of the following actions should the nurse take?, A nurse is assessing a client who had a right Study with Quizlet and memorize flashcards containing terms like A home health nurse is performing a home assessment for safety. CST Study with Quizlet and memorize flashcards containing terms like For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?, When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process?, A client has experienced a pontine stroke which has resulted in severe hemiparesis. CN I - olfactory b. 9%) had nursing experience of more than 10 years, and 64 (48. Assistance of neighbors d. 1995). The majority of nurses (107; 81. Carefully Study with Quizlet and memorize flashcards containing terms like A patient has had an ischemic stroke and has been admitted to the medical unit. B) Assist the patient in acutely flexing the thigh to promote movement. Orient the client to his room B. Which actions would the nurse take? Select all that apply. Monitoring respiratory status A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. What should the nurse do prior to the interview in order to facilitate communication? Select all apply. Home environment b. Clients who have a fracture can develop a deep-vein thrombosis, which can lead to pulmonary embolism. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran. The client says to the nurse, "I am so upset. " When the A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following precautions should the nurse institute before completing the assessment of the client? The nurse is discharging home a client who had a stroke. 25 When located within a nursing home or hospital The nurse is performing a neurological assessment on a client who had a stroke (brain attack). 2006). Which of the following observations should the nurse identify as proper protocol. A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. and the subacute and long-term assessment of patients who have had a stroke are discussed Study with Quizlet and memorize flashcards containing terms like The home health nurse is caring for an 81-yr-old patient who had a stroke 2 months ago. The client reports black tarry stools and abdominal pain immediately after eating. 2- Provide adequate caffeine-rich drinks to the client. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Discussing practical considerations and concerns with medical professionals, as well as making changes to the home environment, can help to ease Chapter 8 discussed how nursing assistants help clients with mobility with actions ranging from repositioning them in bed, transferring them out of bed to a chair, or ambulating them in the hallway. A client who has a femur fracture and reports feeling short of breath When using the urgent vs. The nurse should ask the client if they would like which of the following foods or beverages excluded from meals?, A nurse is assessing a client who has a rash on their hands and forearms Study with Quizlet and memorize flashcards containing terms like The nurse caring for a client with a history of transient ischemic attacks (TIAs) is reviewing medications ordered to prevent a stroke. TIA increases the risk of stroke. The student understands that which categories of client functioning are included in this assessment? Select all that apply. To promote safety during the examination, the nurse stands A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Check the client's airway C. Which activity would be an example of the nurse navigator role for this client? A. The nurse is performing stroke Assessment of a client reveals signs and symptoms of Paget's disease. Monitor Glasglow Coma Scale A nurse is reinforcing teaching about home safety for a client who has a history of falls. Dim lighting The nurse should refer the client to a social worker upon identifying unsafe stairs in the client's home after a stroke, as social workers can connect clients to A nurse is performing a home safety assessment for a client who has experienced a stroke. Depression D. Oxycodone/acetaminophen 7. Communicating with the medical Study with Quizlet and memorize flashcards containing terms like Regular oral hygiene is an essential intervention for the client who has had a stroke. Chapter 17: Acid Base Imbalances. Monitoring mental status and level of consciousness D. Based on patient information shown in the accompanying figure, which action would the nurse take? a. The client stores an extra oxygen tank on its side under Study with Quizlet and memorize flashcards containing terms like 2. In which order should the nurse perform the assessment? A. "Have you had any headaches in the past few days?" Study with Quizlet and memorize flashcards containing terms like A client is admitted to the health care facility with a diagnosis of pediculosis capitis. A nurse counsels a young family who is interested in natural family planning. Which of the following responses by the nurse is appropriate? "Incorporate nonverbal cues in the conversation. Which of the following actions should the nurse plan to take?, A nurse is planning to perform a sterile dressing change for a client. 9%) nurses had five years of nursing experience with stroke It requires immediate multi-professional intervention in health services, with rapid diagnosis and individualized, specialized, and quality nursing care. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? Check the client's cheek on the affected side after meals to be sure no food This could be anything from confusion all the way to a coma. The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. )formation of collateral blood circulation. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. 45 terms. The nurse note that the stairs in the client's home are in disrepair and pose a safety risk. Reflex response 3. What assessment finding constitutes an early sign of deterioration? a) Generalized pain b) Alteration in level of consciousness (LOC) c) Tonic-clonic seizures d) Shortness of breath, A nurse is communicating with a client who has The nurse is discharging home a client who had a stroke . cornea blink reflex for ability to see the food tray C. the nurse should plan to assess the client for which of the following? - restricted movement due to abnormal fixation of a joint - a drop in blood pressure that occurs with a change in position - altered gait with dragging of the toes while ambulating Perform a vision field assessment. Next, the nurse should activate the alarm system. There is limited new research in this area since the 2012 edition of this guideline. " Which of the following actions should the nurse take? Refer the client to a social worker. " c) "I The nurse will perform stroke scale assessments as directed by their facility. )decrease of edema in the area. -5 p. Substance Use. The client states, "I cannot afford to have the stairs repaired. Both side rails should not be lowered because the client could fall out of the bed. What response by the charge nurse is best? Anxiety is causing the client to breathe rapidly. Gently pricking the client's skin on the dorsum of the foot in 2 places 3. A client who requires teaching on self-administration of insulin b. Limit the initial interview to 15 minutes. The healthcare professional should suggest that the individual seek assistance from local community resources or charities that may be able a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Ask for assistance from the lift team. The nurse conducts a home safety assessment for a client. What should be assigned to the assistive personal? (SATA)-Assist the client with a partial bed A home health nurse is conducting a home safety assessment for an older adult client. Which of the following information should the nurse include? A nurse is performing a skin assessment of an older adult client and identifies an area of tissue sloughing, eschar, and exposed muscle on the sacrum. The nurse coordinates the plan of care with the physical therapist. A nurse is performing an admission assessment on a new client. Raise the four side rails of the clients's bed 4. Which test is the nurse performing on this client? The nurse is caring for a client after a stroke rendered the client's right side weaker than the left. Which nursing diagnosis should the PN use as the highest priority for this client after the surgery?, The practical nurse (PN) is performing a focused assessment for a Background/Purpose: To prevent falling, a common incident with debilitating health consequences among stroke survivors, it is important to identify significant fall risk factors (FRFs) towards developing and implementing predictive and preventive strategies and guidelines. A nurse arranges for physical therapy for a client who had a stroke. What symptoms would the nurse Study with Quizlet and memorize flashcards containing terms like The night charge nurse is making assignments for the next shift. The main evidence is summarised in a Cochrane systematic review (Legg et al, 2006) which found that people with stroke who received occupational therapy targeting PADL performed better and had a reduced risk of a poor outcome (dependency in PADL, deterioration or death) Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Oxycodone/acetaminophen is a combination of an opioid and a nonopioid analgesic medication and is an appropriate medication to administer to the 16-20 Moderate to severe stroke 21-42 Severestroke 20 ACUTE ASSESSMENT SCALES NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS) • Strength: Reliable tool to rapidly assess effects of stroke Medical providers and registered nurses expertly trained in the use of the scale are proven to have similar levels of accuracy The nurse should instruct the clients to perform the examination at which time?, The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which of the following instructions should the nurse include in the teaching? Use tracheostomy covers when outdoors Explanation: The cover protects the client's airway from air, dust, and airborne particles Stroke is a medical emergency and care provided in the first hours is critical in shaping patients’ long-term recovery and prognosis. What nursing actions help prevent this potential complication during hospitalization? Select all that apply. Uncaps the distal end of the tubing 2. Which of the following findings are a safety hazards for the client? The initial nursing assessment of the patient with stroke after admission to the hospital should include evaluating the patient’s vital signs, particularly oxygen saturation, BP, The nurse conducts a home safety assessment for a client. 2%) nurses were staff nurses. Which of the following is not considered an increased risk factor for falls? Iron or vitamin supplementation would be appropriate if the client had nutritional problems. A healthcare professional is conducting a risk evaluation for a patient who suffered a cerebral event. According to the American Stroke Association (ASA), it is the most widely used tool for evaluating The majority of the sample (107; 81. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most In-hospital stroke events occur less often than stroke outside of a health care facility; yet, the need for timely evaluation and treatment is the same regardless of geographic location. 1. Not all of these will affect everyone that has sustained a brain injury. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. Which assessment question would elicit data specific to this type of stroke? 1. The client will be satisfied with the care environment. Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals facing cerebrovascular accident (CVA). ensure the client receives a soft diet. These are the most important diagnostic tests to confirm or rule out a When ambulating, the client should move the cane first. For one client, the nurse last palpates the radial pulse at 120 mm Hg. Approximately two-thirds of stroke patients suffer initially from disturbed mobility (Jorgensen et al. A nurse is performing a home safety assessment for a client who has experienced a stroke. Which action would require intervention by the nurse? A. aev sysdcg sfpw trxra mmjbqn zsf ysuic qfgu nkqlw ldvgk