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 C
Explanation
Choice A reason: The client's code status is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. The code status indicates the level of resuscitation the client wishes to receive in case of a cardiac or respiratory arrest.
Choice B reason: The client's vital signs are not part of the background information, but rather the assessment section of the SBAR Communication tool. The vital signs reflect the client's current condition and response to treatment.
Choice C reason: The client's name is part of the background information, along with the client's age, diagnosis, reason for admission, and relevant medical history. The background information provides a brief overview of the client's situation and helps to identify the client.
Choice D reason: A prescribed consultation is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. A consultation is a referral to another health care professional for further evaluation or management of the client's condition.
Correct Answer is A
Explanation
Choice A reason: The client's current location and status are important information that the nurse should include in the report, as they affect the continuity and quality of care. The nurse should also inform the oncoming nurse of the reason and results of the chest x-ray, if available.
Choice B reason: The client's partner's visit is not relevant information that the nurse should include in the report, as it does not affect the client's care plan or outcomes. The nurse should focus on the client's clinical data and needs, not their personal or social information.
Choice C reason: The client's routine vital signs are not specific information that the nurse should include in the report, as they do not reflect the client's current condition or changes. The nurse should provide the actual vital signs values and trends, as well as any interventions or responses related to them.
Choice D reason: The client's occupation is not pertinent information that the nurse should include in the report, as it does not influence the client's care plan or outcomes. The nurse should respect the client's privacy and confidentiality and avoid disclosing unnecessary or sensitive information.
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