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 D
The correct answer is Choice D.
Choice A rationale: Ambulation assistance is expected in rehabilitation. It reflects motor recovery needs but does not pose an immediate safety or health risk requiring urgent referral.
Choice B rationale: Difficulty using utensils indicates fine motor deficits. While important for occupational therapy, it’s not a priority compared to airway protection concerns.
Choice C rationale: Expressive aphasia affects communication but does not compromise physical safety or airway integrity. Speech therapy is appropriate but not urgent.
Choice D rationale: Coughing after drinking signals aspiration risk. This can lead to pneumonia or airway obstruction, requiring immediate referral to speech-language pathology for swallow evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Verifying placement of a nasogastric tube requires specialized training and knowledge to ensure correct placement and prevent complications. The nurse should retain this task to ensure patient safety.
Choice B rationale:
Evaluating a client's understanding of how to use crutches involves assessing the client's comprehension and ability to use crutches safely and effectively. This task requires nursing judgment and should not be delegated to an assistive personnel.
Choice C rationale:
Replacing the gauze on a skin abrasion is a task that can be safely assigned to an assistive personnel. It involves basic wound care, which typically falls within the scope of practice for assistive personnel. The AP can be trained to follow established protocols for wound cleaning and dressing changes.
Choice D rationale:
Monitoring bowel sounds requires clinical judgment and the ability to recognize variations from the normal range. The nurse should perform this task, as it involves assessing the client's condition and making appropriate decisions based on the findings.
Correct Answer is C
Explanation
Choice A rationale:
The walking gait test is used to assess a client's walking pattern and balance, particularly for identifying abnormalities in gait. However, it doesn't specifically evaluate sensory functions, making it an inappropriate choice for this scenario.
Choice B rationale:
The plantar reflex test, also known as the Babinski reflex test, assesses the neurological integrity of the corticospinal tract. It involves stimulating the sole of the foot to elicit specific reflex movements. While this test is important in assessing neurological function, it doesn't directly evaluate sensory functions as requested in the question.
Choice C rationale:
The finger-to-nose test is a part of the neurological examination used to assess a client's coordination and proprioception. In this test, the client is asked to touch their nose with their index finger while alternating between eyes closed and eyes open. This evaluates their ability to sense the position of their limbs in space (proprioception) and their coordination. It directly addresses the focus of the question, making it the correct choice.
Choice D rationale:
The Romberg test evaluates a client's balance and proprioception. It involves having the client stand with their feet together and their eyes closed to assess their ability to maintain balance without visual input. While this test is relevant to sensory functions, it primarily assesses proprioception and balance rather than coordination, which the question is specifically targeting.
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