A nurse is caring for a client who has had a stroke. Client had a left hemisphere stroke w/ right side arm weakness and mild espressive aphasia.
A nurse is caring for a client who has had a stroke. Client had a left hemisphere stroke w/ right side arm weakness and mild espressive aphasia. Client is able to ambulate w/ minimal assistance. Client is alert to person place but is unable to remember date and time. Nurses notes: 1000 client is assisted out of bed to chair, sitting up right eating breakfast. Bilateral breath sounds clear and present throughout. Client drools and clears throat when eating. Voice hoarse after swallowing. 1800 client coughing frequently. Breath sounds w/ crackles heard in right upper lobe. VS: 1000 – Temp. 99 F; BP 128/76, HR 86, RR 18, O2 96 1800 – Temp. 103.3F; BP 118/78, HR 104, RR 24, O2 92 on room air Select three findings that require immediate follow-up by the nurse Temperaure at 1800 BP at 1800 Breath sounds at 1000 Drooling Hoarseness
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