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Case Study: The nurse is preparing a 68-year-old client in a rehabilitation center for discharge to home. The client was transferred from the hospital 2 weeks ago following treatment for a right cerebral stroke. On admission to the rehabilitation center, the following findings were documented. Nurses Notes Vital Signs Physician’s Orders Client is accompanied by spouse, who will be the primary caregiver when the client returns home.Alert and oriented and understands about receiving rehabilitative therapy before returning to home. States doesn’t really have “much to rehab” and is fine but will do what the doctor says to get home. Has left-side weakness and seems impulsive with movements. Able to move right arm and leg with adequate strength noted.Has difficulty focusing and attention span is short; spouse is assisting in answering questions.Spouse notes that the client’s judgment is impaired and is concerned about the client’s safety because of the client’s impulsivity.Client also exhibits left-sided neglect; lacks proprioception.Has homonymous hemianopsia. T = 98.6°F  HR = 92 BPM BP 132/78 RR = 20 bpm SpO2 = 95% on RA PT and OT evaluation and initiate a treatment plan as neededLow-fat dietOut of bed as much as toleratedBegin to prepare client and spouse for discharge to homeReferral to case manager to plan dischargeClopidogrel 75 mg oral dailyCarvedilol 3.125 mg oral twice dailyDocusate 100 mg oral dailySimvastatin 20 mg oral daily Which client or spouse statement/observation indicates that the home care instruction is either understood or requires further teaching? Spouse states: “It will help vision if I approach my spouse from the right side.”: [statement1] Client turns the head to the right and then to the left before taking on an activity.: [statement2] Client states: “I know that I need to call for help if I need to use the bathroom.”: [statement3]  

The nurse is completing discharge education with a patient who underwent a mechanical heart valve replacement. Which of the following statements by the client indicates understanding of the teaching?

A nurse is caring for a client who is exhibiting a rhythm with no visible P waves, a PR interval not measurable, an R-R interval regular, a ventricular rate in the 170’s, and QRS complex wide and distorted. The patient is pulseless with no spontaneous respirations. What intervention should the nurse prepare for?

A nurse is caring for a patient admitted with an ischemic stroke. Which priority intervention should the nurse anticipate within the 4.5 hours of symptom onset?

https://mededu.azureedge.net/restricted/ekgtracingsRr/5.gif A patient’s heart monitor displays a pattern of varying contours and amplitude with no measurable ECG pattern. The nurse enters the room to see the patient is unresponsive and feels no palpable pulse. Which action should the nurse take first?

A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 144 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Diltiazem (Cardizem) are administered. The nurse caring for the client understands that the main goals of treatment include all of the following except:

A nurse is providing teaching for a new graduate nurse. Which of the following statements is correct about unstable angina and should be included in the teaching?

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action will the nurse take first?

Which signs and symptoms in an older client receiving a blood transfusion indicate to the nurse that the client is experiencing transfusion-associated circulatory overload (TACO)

The nurse is caring for a 70-year-old client who had a cardiac catheterization yesterday to confirm an MI and has completed discharge teaching using the teach-back method. This morning the nurse is evaluating the client’s understanding of the discharge plan of care. For each of the statements made by the client, specify whether the statement indicates an Understanding or Requires Further Education of the teaching provided. “I will take only my aspirin and not the clopidogrel.”: [statement1] “I will be sure to carry my nitroglycerin with me.”: [statement2] “I will exercise indoors only.”: [statement3]