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 {"xRanges":[124.765625,154.765625],"yRanges":[96.609375,126.609375]}
Explanation
is not the correct answer because the tricuspid area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The tricuspid area is located at the fifth intercostal space at the lower left sternal border, and is the site where blood flows from the right atrium to the right ventricle during systole.<\/p>"},"B":{"choice":"-","reason":"
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"},"C":{"choice":"-","reason":"
is not the correct answer because the aortic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The aortic area is found at the second intercostal space at the right sternal border, and is the site where blood flows from the left ventricle to the aorta during systole.
\r\nChoiceD4 is not the correct answer because the pulmonic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The pulmonic area is located at the second intercostal space at the
\r\n
\r\nleft sternal border, and is the site where blood flows from the right ventricle to the pulmonary artery during systole.<\/p>"},"D":{"choice":"-","reason":"
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"}}
Correct Answer is B
Explanation
A platelet count of 60,000/mm² is below the expected reference range, and the nurse should report this value to the provider. Ammonia, aspartate aminotransferase, and bilirubin values are within expected reference ranges and do not require further reporting.
Other choices are not correct because:
A. Ammonia 55 mcg/dL: Is within the expected reference range and does not require further reporting.
C. Aspartate aminotransferase 34 units/L: Is within the expected reference range and does not require further reporting.
D. Bilirubin 1.0 mg/dL: Is within the expected reference range and does not require further reporting.
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