A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?
Difficulty performing ADLs
Inability to swallow clear liquids
Elevated blood glucose levels
Unsteady gait when ambulating
The Correct Answer is A
- A. Correct. Difficulty performing ADLs such as dressing, grooming, bathing, or feeding may indicate that the client has impaired motor function, sensory perception, or cognitive ability due to the stroke, which can affect their independence and quality of life. Occupational therapy can help the client regain or adapt their skills and abilities for daily living.
- B. Incorrect. Inability to swallow clear liquids may indicate that the client has dysphagia or impaired swallowing function due to the stroke, which can increase their risk of aspiration and malnutrition. Speech therapy can help the client improve their swallowing function and provide recommendations for safe oral intake.
- C. Incorrect. Elevated blood glucose levels may indicate that the client has diabetes mellitus or impaired glucose metabolism due to the stroke, which can affect their healing and recovery process and increase their risk of complications such as infection or hyperglycemia/hypoglycemia episodes. Diabetes education and management can help the client control their blood glucose levels and prevent adverse outcomes.
- D. Incorrect. Unsteady gait when ambulating may indicate that the client has impaired balance, coordination, or muscle strength due to the stroke, which can affect their mobility and safety and increase their risk of falls or injuries. Physical therapy can help the client improve their gait and mobility and provide assistive devices if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: The Agency for Healthcare Research and Quality is a federal agency that conducts research on health care quality, access, and outcomes. It provides specific data on migrant farmworkers.
B: The National Institutes of Health is a federal agency that supports biomedical and behavioral research. It does not provide specific data on migrant farmworkers.
C: The Department of Agriculture is a federal agency that oversees agricultural production, food safety, nutrition, and rural development. It does not collects comprehensivedata on migrant and seasonal farmworkers, such as their demographics, health status, and access to health care.
D: The World Health Organization is an international organization that works to improve global health and coordinate responses to health emergencies. It does not provide specific data on migrant farmworkers in the United States.
Answer is:Department of Agriculture. The Department of Agriculture is a federal agency that oversees agricultural production, food safety, nutrition, and rural development.It also collects and publishes data on migrant and seasonal farmworkers, such as their demographics, health status, and access to health care1.
Statement is wrong because: Agency for Healthcare Research and Quality (AHRQ) is an independent agency within the U.S.Department of Health and Human Services that conducts research to improve the quality, safety, efficiency, and effectiveness of health care2.National Institutes of Health (NIH) is a federal agency that supports biomedical research and public health initiatives3. World Health Organization (WHO) is a specialized agency of the United Nations that is concerned with international public health.
Correct Answer is A
Explanation
The adolescent has not voided in 4 hr.
Rationale:
- A. The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
- B. The adolescent's blood pressure is 131/89 mm Hg. This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
- C. The adolescent reports severe pain. This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
- D.Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.
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