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 C
Explanation
The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.
Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.
Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.
Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.
Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.
Correct Answer is A
Explanation
Ringing in ears. Furosemide is a loop diuretic, which can cause ototoxicity as an adverse effect, resulting in ringing in the ears, hearing loss, or vertigo. The nurse should instruct the client to monitor for these adverse effects and report them immediately if they occur.
An explanation for incorrect choices:
B. Metallic taste is a common adverse effect of metronidazole or clarithromycin, but not furosemide.
C. Rhinitis is associated with intranasal or occasionally oral corticosteroid use.
D. Agitation is a side effect for stimulants, sedatives, or antidepressants.
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