# A home health nurse visits a 74-year-old client 6 months after a right middle cerebral artery stroke with residual left hemiparesis and mild aphasia. In the past month the client has missed 5 of 8 physical, occupational, and speech therapy visits because the spouse could not arrange transportation, and has fallen twice during transfers without injury. The spouse reports interrupted sleep, says transfers no longer feel safe, and shows three medication lists from different prescribers that disagree about the antihypertensive dose. Today the neurologic examination is unchanged from discharge, blood pressure is 134/80 mm Hg lying and 130/78 mm Hg standing, and the client's PHQ-9 score is 4. The client says, "I want to keep going to therapy." Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617406&lang=en  
> language: en  
> subject: Case Management  
> category: MOC

## Question

A home health nurse visits a 74-year-old client 6 months after a right middle cerebral artery stroke with residual left hemiparesis and mild aphasia. In the past month the client has missed 5 of 8 physical, occupational, and speech therapy visits because the spouse could not arrange transportation, and has fallen twice during transfers without injury. The spouse reports interrupted sleep, says transfers no longer feel safe, and shows three medication lists from different prescribers that disagree about the antihypertensive dose. Today the neurologic examination is unchanged from discharge, blood pressure is 134/80 mm Hg lying and 130/78 mm Hg standing, and the client's PHQ-9 score is 4. The client says, "I want to keep going to therapy." Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Fragmented care with caregiver strain
Recurrent ischemic stroke with new deficits
Orthostatic hypotension causing recurrent falls
Post-stroke depression with disengagement

Actions to take

Select 2
Refer the client for an antidepressant evaluation
Reconcile medications from all three prescribers
Arrange emergency department transport for imaging
Recommend long-term care facility placement
Arrange home-based therapy and transfer training

Parameters to monitor

Select 2
PHQ-9 depression screening score
NIH Stroke Scale score
Falls since the last visit
Serum LDL cholesterol level
Caregiver strain index score

## Explanation

Missed therapy due to transportation, unsafe transfers, conflicting medication lists, and an exhausted spouse point to fragmented care and caregiver strain, not a new medical event. The nurse reconciles medications and brings therapy and transfer training into the home. Fall frequency and a caregiver strain score show whether coordination is working. The stable neurologic exam, normal orthostatic readings, and low PHQ-9 rule out the differentials.

## In-depth explanation

Quick answer
Fragmented care with caregiver strain after stroke; reconcile medications across prescribers, arrange home-based therapy with transfer training, and monitor the number of falls and the caregiver strain index score.

Why this is correct
Every cue traces back to a coordination gap: no transportation, therapy missed, transfers unsafe, prescribers not talking to each other, and a spouse who is exhausted. The scenario deliberately rules out a medical cause of the falls: the neurologic examination is unchanged, the blood pressure does not drop on standing, and the PHQ-9 score is minimal. Case-management actions that remove the barriers address the real problem.

Easy analogy or mental picture
Picture a relay race where the baton keeps being dropped between runners: the runners are healthy, but the handoffs fail. The nurse repairs the handoffs.

Memory hook
Stable exam + missed visits + tired caregiver = coordinate, reconcile, bring care home.

NCLEX decision rule
Before labelling falls as a new medical problem, check the data that rule it in or out; if they are negative, target the care-delivery barrier and measure outcomes the plan can change.

Why the other choices are wrong
Recurrent stroke is unlikely with an unchanged neurologic examination, so emergency imaging and an NIH Stroke Scale trend are not indicated. A standing drop of only 4 mm Hg rules out orthostatic hypotension. A PHQ-9 score of 4 and a client who wants therapy argue against depression, so an antidepressant referral and PHQ-9 tracking do not address the cause. Long-term placement may be discussed later but is premature when the client wants to continue and services have not been tried. LDL cholesterol reflects secondary prevention, not this care gap.

References
1AHA/ASA — Guidelines for Adult Stroke Rehabilitation and RecoveryStroke rehabilitation should include coordinated care, fall prevention, and caregiver training and support.
2AHRQ — Transitions of CareCare coordination and medication reconciliation reduce harm during transitions.

## Clinical scenario

Scenario
Six months after a stroke, a client has missed most therapy visits, fallen twice during transfers, and has an exhausted spouse holding conflicting medication lists; neurologic, orthostatic, and mood screens are stable.

## Key concepts

- **Medication reconciliation** — Comparing all medication lists to create one accurate list and resolve discrepancies.
- **Caregiver strain index** — A brief validated tool that quantifies caregiver burden.
- **Transitional care** — Coordinated services that maintain continuity of care as a client moves between settings.

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