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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.

A. Form a committee of staff members to investigate current staffing issues. B. Provide support to staff members who are resistant to staffing changes. C. Schedule a staff meeting to present the different options to staff members. D. Give the staff members advance written notice of staffing changes.

Correct Answer is A

Explanation

A. Form a committee of staff members to investigate current staffing issues:This action is the best first step as it engages staff members directly in identifying the underlying causes of staffing difficulties. Involving staff in the problem-solving process can lead to more effective solutions and promote buy-in for any changes.

B. Provide support to staff members who are resistant to staffing changes:While supporting staff is important, this step should come after understanding the issues and gathering input. Addressing resistance without first identifying the root causes may not be effective.

C. Schedule a staff meeting to present the different options to staff members:While communication is important, presenting options without first gathering input and understanding the current issues may not address the root problems. A meeting should follow the investigation and data collection.

D. Give the staff members advance written notice of staffing changes:Notifying staff of changes is important, but it should come after the issues are investigated and a plan is formed. Implementing changes without understanding staff concerns may lead to further dissatisfaction.

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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?

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