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 C
Explanation
a. Administer the medication and alert the charge nurse: This choice suggests proceeding with medication administration but also informing the charge nurse. While it's important to communicate with the charge nurse regarding medication administration, in this scenario, there is no indication to hold the medication as the infant's heart rate is within the normal range. Therefore, alerting the charge nurse may not be necessary at this point.
b. Hold the medication and document cardiac assessment: This choice suggests holding the medication and documenting the cardiac assessment. However, since the infant's heart rate is within the normal range for their age, there is no clinical indication to hold the medication. Holding the medication unnecessarily could delay treatment and potentially lead to adverse outcomes if the medication is needed.
c. Administer the medication and document the heart rate.
Since the infant's heart rate of 120 beats per minute falls within the normal range for a 2-month-old, there is no indication to hold the medication. Administering the digoxin as prescribed and documenting the heart rate before administration are appropriate actions. It's important to ensure accurate documentation to track the infant's response to the medication and monitor for any changes in heart rate.
d. Hold the medication and recheck the heart rate in 1 hour: This choice suggests holding the medication and rechecking the heart rate in 1 hour. Again, since the infant's heart rate is within the normal range, there is no clinical indication to hold the medication or delay treatment. Rechecking the heart rate in 1 hour would be unnecessary and could potentially delay necessary medication administration.
Correct Answer is C
Explanation
A. Incorrect. Organizing the work environment is an important step of the time management process, but it is not the priority. The nurse manager should first identify the activities that need to be done before organizing them.
B. Incorrect. Delegating assigned tasks appropriately is an important step of the time management process, but it is not the priority. The nurse manager should first determine which tasks can be delegated and which ones require their direct involvement before assigning them to others.
C. Correct. Making a list of activities to complete is the priority step of the time management process, as it helps the nurse manager to identify and prioritize their goals and responsibilities.
D. Incorrect. Rewarding yourself for accomplishing goals is an important step of the time management process, but it is not the priority. The nurse manager should first complete the tasks that are essential and urgent before rewarding themselves for their achievements.
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