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 is a correct statement by the newly licensed nurse. Airborne precautions are used for clients who have infections that can be transmitted through the air, such as tuberculosis, chickenpox, or measles. The nurse should have the client wear a mask when leaving the room to prevent spreading the infection to others.
Choice B reason: This is an incorrect statement by the newly licensed nurse. A negative-pressure airflow room is used for clients who are on airborne precautions, not for clients who have compromised immunity. A negative-pressure airflow room prevents contaminated air from escaping the room and infecting others. A client who has compromised immunity should be placed in a positive-pressure airflow room, which prevents outside air from entering the room and exposing the client to pathogens.
Choice C reason: This is an incorrect statement by the newly licensed nurse. An N95 respirator mask is used for clients who are on airborne precautions, not for clients who are on droplet precautions. Droplet precautions are used for clients who have infections that can be transmitted through respiratory droplets, such as influenza, pertussis, or meningitis. The nurse should wear a surgical mask, not an N95 respirator mask, when caring for a client who is on droplet precautions.
Choice D reason: This is an incorrect statement by the newly licensed nurse. Visitors do not need to wear a mask when visiting a client who is on contact precautions, unless they are in direct contact with the client or the client's environment. Contact precautions are used for clients who have infections that can be transmitted through direct or indirect contact, such as MRSA, VRE, or C. difficile. The nurse should wear gloves and a gown, and perform hand hygiene before and after caring for a client who is on contact precautions.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this situation is the most urgent and requires immediate action. The charge nurse should prioritize the new admission and assign a staff nurse to receive the report and prepare the room for the client. The charge nurse should also ensure that the client's needs are met and that the admission process is smooth and efficient.
Choice B reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should plan the staffing for the shift and arrange for replacements or reassignments if necessary. The charge nurse should also communicate with the staff members who called in and document their reasons for absence.
Choice C reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should coordinate with the transport department and the occupational therapy department to reschedule the client's appointment or find an alternative way to transport the client. The charge nurse should also inform the client and the staff nurse about the change and apologize for any inconvenience.
Choice D reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should review the incident report and follow up with the nurse who wrote it and the client who was involved. The charge nurse should also implement corrective actions and preventive measures to avoid similar errors in the future.
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