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

The correct answer is: D.

Choice A reason: Asking a patient to rate their pain on a scale from 0 to 10 is a common method to assess the intensity of pain, not the quality. Zero indicates no pain, and ten represents the most severe pain imaginable. This scale is quantitative and helps in tracking the effectiveness of pain management over time.

Choice B reason: Inquiring if the pain is the same as it has been is a question that assesses the consistency or changes in the patient’s pain over time. It does not provide information about the quality of the pain but rather its course or any variations in the experience of pain.

Choice C reason: Asking whether the patient has any pain this morning is a question that determines the presence or absence of pain at a particular time. It does not elicit details about the nature or characteristics of the pain, which are essential to understanding its quality.

Choice D reason: Asking “What does your pain feel like?” is a qualitative question that aims to describe the characteristics of the pain, such as aching, stabbing, or burning. This information is crucial for diagnosing the cause of pain and tailoring appropriate treatment strategies. It directly addresses the quality of the pain, which is the focus of the nurse’s inquiry.

A. Monitor for muscle paralysis. B. Place in contact isolation. C. Check for increased salivation. D. Administer clindamycin hydrochloride.

Correct Answer is A

Explanation

The nurse should include monitoring for muscle paralysis in the plan of care for a client with botulism poisoning. Botulism is a serious bacterial illness that can cause muscle paralysis and can be life threatening. Monitoring for muscle paralysis is essential for early detection and intervention.

Choice B is incorrect because contact isolation is not necessary for the treatment of botulism.

Choice C is incorrect because increased salivation is not a common symptom of botulism.

Choice D is incorrect because clindamycin hydrochloride is not used to treat botulism.

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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

A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?

Correct Answer is D

Explanation

A nurse is assisting with the plan of care for a client who has botulism poisoning. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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