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 D

Explanation

A. Calories is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate calories to prevent malnutrition and weight loss due to inflammation, malabsorption, and increased metabolic rate.

B. Protein is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate protein to promote tissue healing and prevent protein-losing enteropathy.

C. Potassium is incorrect. Clients with Crohn's disease and enteroenteric fistula are at risk of hypokalemia due to diarrhea, vomiting, and fistula drainage. They need to increase their potassium intake to prevent electrolyte imbalance and cardiac complications.

D. Fiber is correct. Clients with Crohn's disease and enteroenteric fistula should decrease their fiber intake to reduce intestinal motility, bulk, and gas production, which can worsen the inflammation and fistula formation.

A. Natural loss of deciduous teeth B. Nontender, protruding abdomen C. Head circumference exceeds chest circumference D. Palpable fontanels

Correct Answer is B

Explanation

Choice A reason:

Natural loss of deciduous teeth is incorrect. Natural loss of deciduous teeth, also known as baby teeth, usually begins around the age of 5 or 6 years. At the age of 2, a toddler would still have their baby teeth.

Choice B reason:

This is a normal finding in toddlers. It is common for toddlers to have a protruding abdomen due to their body composition and the normal development of their abdominal muscles.

Choice C reason:

Head circumference exceeds chest circumference: In a typical 2-year-old toddler, the head circumference should be less than the chest circumference. The head grows rapidly during infancy and slows down as the child grows older, leading to a cage in the head-to-chest ratio.

Choice D reason:

The fontanels, or soft spots on the skull, usually close by the end of the first year. By age 2, the fontanels should be closed or very close to being closed, and they would not typically be palpable.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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