A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

"I just don't think I can handle looking at my leg."

"I am worried about taking care of my toddler at home."

"I hope I can adjust to using crutches while I am recovering

"I am not sure how I will pay for all the therapy I will need."

Answer and Explanation

The Correct Answer is B

A.   Feeling discomfort or distress about looking at the amputated leg might indicate the need for psychological support or counseling but doesn't specifically indicate the need for occupational therapy.
B.   Expressing worry about managing childcare responsibilities at home suggests potential difficulty with daily activities, indicating a need for occupational therapy to assess and address these concerns.
C.   Hoping to adjust to using crutches during recovery indicates a concern related to
mobility, which might involve physical therapy but not necessarily occupational therapy.
D.   Expressing concern about affording therapy doesn't specifically indicate a need for occupational therapy; this might relate more to financial counseling or social work support.

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Correct Answer is B

Explanation

A. Restraints should be applied based on a specific, documented need, not on an as- needed (PRN) basis, to ensure client safety.
B. A nurse can disclose information to a family member with the client's permission. This statement respects the client's right to privacy and confidentiality.
C. It is the responsibility of the doctor and not nurses to inform clients about available treatment options.
D. Administering medications without consent for research purposes is ethically unacceptable and violates the client's rights to autonomy and informed consent.

A. A newly admitted client who has diabetes mellitus and requires initial teaching on self- administration of insulin B. A client who is scheduled for an endoscopy later today and requires an enema C. A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care D. A client who had a myocardial infarction and will be transferring to the unit from the CCU.

Correct Answer is B

Explanation

- A: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.

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A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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