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
knee-chest. During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.
An explanation for incorrect choices:
A. Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.
B. Trendelenburg position
is supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.
C. Prone position is lying face down, which is not suitable for sigmoidoscopy.
Correct Answer is C
Explanation
Clients with a left-sided stroke will have neurological deficits on the right side of the body, including paralysis or weakness. Impaired speech, language, and cognition are also possible. Blood pressure, temperature, and laboratory results may be affected by the stroke, but they are not specific to a left-sided stroke.
Option A, "Blood pressure," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
Option B, "Temperature," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
Option D, "Laboratory results," is incorrect because they may be affected by the stroke, but they are not specific to a left-sided stroke.
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