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 ["C","D","E"]
Explanation
When managing oxygenation for a client in a PACU, the nurse should take several actions. The nurse should add a humidifier to the oxygen device to help prevent dryness of the nasal passages¹. The nurse should also encourage the client to perform deep breathing exercises to promote oxygenation¹. Additionally, the nurse should examine the client's nail beds for signs of cyanosis, which can indicate inadequate oxygenation¹.
Correct Answer is C
Explanation
The client who had a radical mastectomy 36 hours ago and has a surgical drain is the most stable among the given options and is further along in the recovery process. This client may be ready for discharge with appropriate follow-up care instructions, and their bed can be utilized for the incoming clients who were injured in a tornado.
The client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy requires close monitoring and assessment for complications, such as bleeding or changes in neurological status.
The client with cervical cancer and an internal radioactive implant requires specific precautions and monitoring to ensure radiation safety and to manage any potential side effects or complications.
The client who had a lobectomy and has a chest tube drainage system needs continued monitoring of respiratory status and drainage, as well as close observation for any signs of complications or worsening condition.
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