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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A. This is a correct action. Firmly massaging the uterine fundus can help contract the uterus and reduce bleeding by expelling clots and compressing blood vessels.

B. This is a correct action. Providing emotional support can help calm the client and reduce anxiety, which can worsen bleeding by increasing heart rate and blood pressure.

C. This is a correct action. Administering oxygen can help improve tissue perfusion and oxygenation, which can prevent hypoxia and shock due to blood loss.

D. This is a correct action. Weighing the perineal pads can help estimate the amount of blood loss and monitor the effectiveness of interventions to control bleeding.

E. This is a correct action. Inserting an indwelling urinary catheter can help empty the bladder and prevent it from displacing or compressing the uterus, which can interfere with uterine contraction and increase bleeding.

F. This is a correct action. Administering methylergonovine can help stimulate uterine contraction and reduce bleeding by constricting blood vessels in the uterus.

A. "I will not allow anyone to smoke near my baby." B. I will place bumper pads in my baby's crib." C. "My baby's head should be placed on a pillow for sleeping. D. "My baby should sleep in a side-lying position."

Correct Answer is A

Explanation

A. Correct. Avoiding exposure to tobacco smoke is one of the measures to prevent SIDS, as it can affect the respiratory function and arousal of the newborn.

B. Incorrect. Placing bumper pads in the baby's crib is not recommended, as they can pose a suffocation or strangulation hazard for the newborn.

C. Incorrect. Placing the baby's head on a pillow for sleeping is not advised, as it can increase the risk of suffocation or rebreathing of carbon dioxide for the newborn.

D. Incorrect. Placing the baby in a side-lying position for sleeping is not suggested, as it can increase the likelihood of rolling over to a prone position, which is associated with a higher incidence of SIDS.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

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