A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?
The client requires reinforcement of teaching about the purpose of his medications.
The client is unable to grasp eating utensils.
The client requests to perform ADLS later in the day.
The client tells the nurse he prefers a snack before bedtime.
The Correct Answer is B
This issue indicates a potential difficulty with fine motor skills and may impact the client's ability to feed themselves independently.
It is important for the interprofessional team, including occupational therapy and/or physical therapy, to be aware of this issue and collaborate on appropriate interventions to improve the client's functional abilities and promote independence in activities of daily living (ADLs).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Opioid medications can cause urinary retention by inhibiting the normal function of the bladder and reducing the urge to urinate. This can lead to incomplete emptying of the bladder and increased urine retention. Nurses should monitor clients receiving opioids for signs of urinary retention, such as decreased urine output, distended bladder, or discomfort in the lower abdomen.
Opioids generally cause pupil constriction (miosis) rather than dilation (mydriasis). Dilated pupils may indicate other drug use or neurological issues, but they are not a typical adverse effect of hydromorphone.
Hydromorphone is more likely to cause hypotension (low blood pressure) as an adverse effect rather than hypertension (high blood pressure).
Hydromorphone can cause respiratory depression, which is characterized by decreased respiratory rate and depth. Tachypnea (rapid breathing) is not a typical adverse effect of hydromorphone.
Correct Answer is C
Explanation
When caring for a client with paranoid schizophrenia who has delusions or beliefs that are not based in reality, it is important to respond in a therapeutic and empathetic manner. Acknowledging the client's fear and validating their experience can help establish trust and promote open communication.
The response "This must be very frightening for you. Let's talk more about it" demonstrates empathy and a willingness to engage in further discussion, allowing the client to express their concerns and facilitating a therapeutic relationship.
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