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 C
Explanation
Rationale:
A. Check the compatibility of cefazolin with the client's existing IV fluids: Compatibility is important to prevent precipitation or inactivation of the drug, but it should be done only after confirming the medication is safe for the client to receive.
B. Assess the IV for patency: Ensuring the IV line is patent is necessary before administration to avoid infiltration or extravasation, but it is not the first priority when preparing a first-time antibiotic dose.
C. Review the client's allergy history: Reviewing allergies is the first and most critical step, as cefazolin is a cephalosporin that can cause severe allergic reactions, particularly in clients with a history of beta-lactam (e.g., penicillin) allergy. Administering the drug without this check could cause life-threatening anaphylaxis.
D. Obtain the reconstituted antibiotic from the pharmacy: Securing the medication from the pharmacy is part of preparation, but this should only occur after confirming it is safe for the client to receive based on allergy status.
Correct Answer is B
Explanation
Rationale:
A. Abdominal pain: While abdominal pain can occur with peritonitis, it often develops after the initial changes in the dialysate effluent. Pain may also be related to catheter placement or dialysate temperature, so it is not the earliest definitive indicator.
B. Cloudy effluent: Cloudy dialysate is typically the first and most reliable sign of peritonitis in clients receiving peritoneal dialysis. It indicates the presence of white blood cells and infection in the peritoneal cavity before systemic symptoms appear.
C. Nausea: Nausea may occur later as part of the systemic inflammatory response, but it is nonspecific and can be caused by multiple factors, including the dialysis process itself or other gastrointestinal disturbances.
D. Fever: Fever is a later manifestation of peritonitis, often developing after local signs are present. It indicates systemic involvement and immune activation but is not the earliest detectable change.
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