A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
Diminished hand-to-mouth coordination
Impaired voluntary cough
Altered level of consciousness
Unilateral ptosis
The Correct Answer is B
Choice A reason: Diminished hand-to-mouth coordination is not a finding that requires a referral to speech-language pathology, as it is related to the motor function of the upper extremities. The nurse should refer the client to physical therapy or occupational therapy for this issue.
Choice B reason: Impaired voluntary cough is a finding that requires a referral to speech-language pathology, as it indicates a possible dysfunction of the swallowing mechanism or the vocal cords. The nurse should refer the client to speech-language pathology for a swallowing evaluation and intervention.
Choice C reason: Altered level of consciousness is not a finding that requires a referral to speech-language pathology, as it is related to the neurological function of the brain. The nurse should monitor the client's Glasgow Coma Scale score and report any changes to the provider.
Choice D reason: Unilateral ptosis is not a finding that requires a referral to speech-language pathology, as it is related to the cranial nerve function of the eye. The nurse should assess the client's pupillary response and eye movements and report any abnormalities to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as hospice care provides comprehensive and compassionate care for clients who have a life expectancy of six months or less. Hospice care involves a team of health care professionals, such as physicians, nurses, social workers, chaplains, and volunteers, who address the physical, emotional, social, and spiritual needs of the client and their family.
Choice B reason: This statement is incorrect, as hospice care is not intended for clients at various stages of chronic illness. Hospice care is only for clients who are terminally ill and have decided to forego curative or aggressive treatments.
Choice C reason: This statement is incorrect, as hospice care does not prolong the life expectancy of clients who are terminally ill. Hospice care focuses on improving the quality of life and comfort of the client, not on extending their life span.
Choice D reason: This statement is incorrect, as hospital access is still available for clients who are in hospice care. Hospice care can be provided in various settings, such as the client's home, a hospice facility, a nursing home, or a hospital. Clients who are in hospice care can still be admitted to the hospital if they need acute care or symptom management.
Correct Answer is B
Explanation
Choice A reason: This is not the correct choice because checking on a client whose telemetry monitor is continuously beeping is a task that requires nursing judgment and assessment skills. The nurse should not delegate this task to the AP, but rather perform it themselves or notify the health care provider.
Choice B reason: This is the correct choice because tagging a malfunctioning piece of equipment as broken is a task that does not involve direct client care or clinical decision making. The nurse can delegate this task to the AP, who can follow the facility's policy and procedure for reporting and removing faulty equipment.
Choice C reason: This is not the correct choice because determining whether an oxygen flow meter is accurately set at 2 L/min via nasal cannula is a task that involves administering medication and monitoring the client's oxygenation status. The nurse should not delegate this task to the AP, but rather perform it themselves and document the results.
Choice D reason: This is not the correct choice because instructing a client about the use of an incentive spirometer is a task that involves providing client education and evaluating the client's understanding and compliance. The nurse should not delegate this task to the AP, but rather perform it themselves and document the outcomes.
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