A nurse is assisting in the care of a client who had an ischemic stroke. Which of the following observations by the nurse indicates a need for an occupational therapy referral?

The client becomes exhausted while brushing her teeth.

The client coughs while drinking from a straw.

The client is unable to bear her full weight while walking.

The client is having difficulty reading large print.

Answer and Explanation

The Correct Answer is A

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Correct Answer is D

Explanation

Answer is: d. Reposition the client.

Explanation: Repositioning the client can help alleviate pain by redistributing pressure and promoting comfort. Since the client's pain level is relatively low (2 on a scale of 0 to 10), this non-pharmacological intervention is an appropriate initial action.

Choice a. is wrong because maintaining the client on bed rest is not an appropriate action for a pain level of 2. Instead, the nurse should encourage the client to mobilize and perform appropriate exercises to prevent complications related to immobility.

Choice b. is wrong because applying a warm, moist compress to the incision area might not be the best action for a client who is 24 hours postoperative, as it could increase the risk of infection and cause discomfort. Cold compresses are often used in the initial postoperative period to reduce swelling and promote comfort.

Choice c. is wrong because administering an additional dose of pain medication is not necessary at this point, as the client's pain level is relatively low. The nurse should consider non-pharmacological interventions first and reassess the client's pain level to determine the need for further pain relief.

A. Place the client in high-Fowler's position. B. Obtain the client's vital signs. C. Administer heparin to the client. D. Encourage the client to cough and deep breathe.

Correct Answer is A

No explanation

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A nurse is assisting in the care of a client who had an ischemic stroke. Which of the following observations by the nurse indicates a need for an occupational therapy referral?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

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