A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

"I've been having problems with bladder control."

"I have difficulty swallowing food."

"I have a hard time with brushing my hair."

"I would rather be in a wheelchair than use a walker to get around."

Answer and Explanation

The Correct Answer is C

Choice A reason: While bladder control issues can significantly affect a client's quality of life, they are typically managed by a urologist or a specialist in continence, rather than an occupational therapist. Occupational therapy focuses on improving the ability to perform activities of daily living (ADLs), which generally does not include bladder control.

Choice B reason: Difficulty swallowing, known as dysphagia, can be a symptom of myasthenia gravis due to muscle weakness. Although it is a serious concern, it is usually managed with the help of a speech therapist who specializes in swallowing difficulties, rather than an occupational therapist.

Choice C reason: Having a hard time with brushing hair is directly related to the performance of ADLs, which is the primary focus of occupational therapy. An occupational therapist can assist the client by teaching energy conservation techniques, providing adaptive equipment, and modifying the task to make it easier for the client to maintain personal grooming independently.

Choice D reason: Preferring a wheelchair over a walker is a matter of mobility and personal preference. While occupational therapy can help with mobility issues, this statement alone does not indicate a need for occupational therapy unless the client has difficulty performing ADLs due to the choice of mobility aid.

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Correct Answer is A

Explanation

Choice A reason : A severe, throbbing headache is a common and significant manifestation of autonomic dysreflexia. This condition is a potentially life-threatening medical emergency that can occur in individuals with spinal cord injuries, typically above the T6 level. The headache results from a sudden and severe increase in blood pressure due to an exaggerated response of the autonomic nervous system to a stimulus below the level of the injury.

Choice B reason: Hypotension, or low blood pressure, is not a manifestation of autonomic dysreflexia. In fact, the condition is characterized by hypertension, or high blood pressure, which is a critical sign that requires immediate attention to prevent complications such as stroke or seizure.

Choice C reason: Fever is not a direct manifestation of autonomic dysreflexia. While a fever may indicate an infection or other systemic issue, autonomic dysreflexia itself is specifically associated with a rapid onset of high blood pressure and other autonomic disturbances.

Choice D reason: Cyanosis of the head and neck, which refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is not a typical manifestation of autonomic dysreflexia. The condition primarily causes hypertension and its associated symptoms, rather than issues with oxygenation.

A. Respiratory rate of 24/min B. Adventitious breath sounds C. Weight loss of 1.8 kg (4 lb) in the past 24 hours D. Elevation in blood pressure

Correct Answer is C

Explanation

Choice A reason: A respiratory rate of 24/min is slightly higher than the normal range (12-20 breaths per minute) and does not necessarily indicate the effectiveness of furosemide in treating pulmonary edema.

Choice B reason: Adventitious breath sounds, such as crackles or wheezes, are often present in pulmonary edema and would not indicate that the furosemide is effective. The resolution of these sounds would be a better indicator of improvement.

Choice C reason: Weight loss of 1.8 kg (4 lb) in the past 24 hours likely indicates a reduction in fluid retention, which is a desired effect of furosemide in the treatment of pulmonary edema. This diuretic effect reduces the fluid overload, thereby improving the symptoms of pulmonary edema.

Choice D reason: An elevation in blood pressure is not an expected outcome of effective furosemide therapy for pulmonary edema. Furosemide is a diuretic and would more likely lead to a reduction in blood pressure due to fluid loss.

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A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations?

Correct Answer is A

Explanation

A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

Correct Answer is C

Explanation

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