The home care nurse is evaluating a post–cerebrovascular accident (CVA) client 1 week after returning to the home from a rehabilitation setting. Which of the following statements, made by the client, most concerns the nurse?
A) "I am so happy to be home, but I am not able to go upstairs to my bedroom."
B) "I find it difficult to get up so I am remaining in bed until the home health aide comes."
C) "My spouse goes to work in the morning and leaves my lunch at my bed stand."
D) "A lot of family is coming to see me, which is nice but makes me very tired."
C
Feedback:
The nurse analyzes the statements and compares them to Maslow's hierarchy of needs. Leaving the lunch at the bed stand alludes to the fact that the client is alone during the day and either stays in bed or is unable physically to obtain lunch from the kitchen. Being in bed for an extended period is a concern for skin breakdown, and if the client is physically weak, safety is a concern. Living arrangements can be made downstairs. Waiting for a home health aide for assistance is appropriate as long as those arrangements are made. Tiring the client with family visits is a concern but not a safety issue.
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