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.
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Closing the door to the client’s room would help to contain the fire and prevent it from spreading to other areas. However, this should not be the nurse’s first action. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice B rationale: Obtaining a fire extinguisher is an important step in responding to a fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice C rationale: Pulling the fire alarm panel is an important step in alerting others in the facility about the fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice D rationale: The nurse’s primary responsibility is to ensure the safety of the client. If there is a fire in the client’s room, the nurse should first remove the client from the room to ensure their safety. Once the client is safe, the nurse can then take further actions to respond to the fire, such as pulling the fire alarm panel, closing the door to the room, and obtaining a fire extinguisher.
Correct Answer is A
No explanation
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