A nurse is performing a home assessment for a client who has weakness in the lower extremities. Which of the following referrals should the nurse request for the client?
Dietitian
Physical therapy
Case manager
Social services
The Correct Answer is B
Rationale:
A. Dietitian: A dietitian focuses on nutritional needs, which may be beneficial if the client has dietary concerns, but this does not directly address mobility issues related to lower extremity weakness.
B. Physical therapy: Physical therapists specialize in improving strength, balance, and mobility. A referral will help the client develop exercises and strategies to enhance function and reduce fall risk.
C. Case manager: A case manager coordinates healthcare services, but they do not directly provide rehabilitation for weakness. They may be involved later to arrange additional resources after therapy needs are determined.
D. Social services: Social services assist with psychosocial needs, financial support, and community resources, but they are not the primary referral for addressing physical mobility limitations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}
Explanation
Rationale:
- Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
- Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
- Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
- Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
- Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.
Correct Answer is D
Explanation
A. Weight gain 2.3 kg (5 lb): Mild weight gain can occur with oral contraceptive use and is generally not dangerous. This finding does not require immediate reporting.
B. Frequent nausea: Nausea is a common side effect, especially during the first few months of therapy. While bothersome, it is usually not an urgent concern unless severe or persistent.
C. Breast tenderness: Breast tenderness is a common, mild side effect of oral contraceptives and does not typically indicate a serious problem requiring immediate intervention.
D. Persistent headache: A new, persistent, or severe headache can indicate vascular complications, such as hypertension or increased risk of thromboembolism, which are serious adverse effects of oral contraceptives. This finding requires immediate reporting.
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