A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?
A client who needs assistance when ambulating.
A client who consistently has difficulty using utensils while eating.
A client who has expressive aphasia.
A client who consistently coughs after drinking liquids.
The Correct Answer is C
Choice A rationale:
A client who needs assistance when ambulating is an important consideration for care, but it does not necessarily require a priority referral. The nurse can assess the client's mobility and coordinate assistance within the rehabilitation unit as needed.
Choice B rationale:
A client who consistently has difficulty using utensils while eating is a concern for occupational therapy or speech therapy, but it is not an immediate priority. The client's difficulty with eating utensils can be addressed through therapeutic interventions within the rehabilitation setting.
Choice C rationale:
A client who has expressive aphasia requires a priority referral because this indicates potential communication difficulties that could hinder the client's ability to express needs, understand instructions, and participate in therapy. Expressive aphasia can impact the client's overall rehabilitation progress and safety.
Choice D rationale:
A client who consistently coughs after drinking liquids might require assessment and intervention, but it does not present an immediate priority. The nurse can address this concern within the rehabilitation unit and collaborate with the interdisciplinary team as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Scheduling the client as the last surgery of the day is not directly related to the client's latex allergy. It might not be feasible to always schedule the client last, and this action does not specifically address the client's needs related to latex exposure.
Choice B rationale:
Notifying ancillary departments of the client's latex allergy is an important step to ensure the client's safety during the surgical process. This action helps other departments prepare and prevent accidental latex exposure, which could trigger an allergic reaction in the client.
Choice C rationale:
Labeling the surgical suite as latex-free is crucial to preventing latex exposure during the surgery. It alerts all staff members entering the surgical suite about the presence of a latex-allergic patient and reminds them to take appropriate precautions.
Choice D rationale:
Providing powdered gloves for the staff's use is not recommended, as powdered gloves can actually carry latex proteins and increase the risk of latex exposure. Powdered gloves have been associated with allergic reactions, so it's important to avoid their use in a latex-sensitive environment.
Choice E rationale:
Ensuring a latex allergy cart is available is a proactive measure to have necessary equipment and supplies on hand in case of an allergic reaction. This cart would contain latex-free items and medications that can be used to manage an allergic reaction should it occur during or after surgery.
Correct Answer is A
Explanation
Choice A rationale:
In the "background" portion of the SBAR communication tool, the nurse should include the client's present condition. This information provides the provider with context and a clear understanding of the client's current status. It helps the provider to have a baseline understanding before moving on to the assessment and recommendation stages of the communication. Including the client's present condition allows the provider to quickly grasp the urgency and severity of the situation, enabling them to make informed decisions regarding the client's care.
Choice B rationale:
Suggestions for the provider regarding client care are typically included in the "assessment" or "recommendation" portions of the SBAR communication tool, rather than the "background" portion. The "background" portion is focused on providing information about the current situation and the client's present condition, setting the stage for the rest of the communication.
Choice C rationale:
Physical findings are part of the assessment and observation of the client's current condition. While important, these findings are better suited for the "assessment" portion of the SBAR communication. The nurse should summarize the physical findings in the "assessment" section after providing the context in the "background" section.
Choice D rationale:
Previous treatments are also relevant information, but they belong in the "assessment" or "background" portions of the SBAR communication tool. The nurse should provide the provider with information about the client's current condition before discussing previous treatments, as the provider needs to know the current situation before considering the relevance of past interventions.
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