A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

A client who needs assistance when ambulating.

A client who consistently has difficulty using utensils while eating.

A client who has expressive aphasia.

A client who consistently coughs after drinking liquids.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A client who needs assistance when ambulating is an important consideration for care, but it does not necessarily require a priority referral. The nurse can assess the client's mobility and coordinate assistance within the rehabilitation unit as needed.

Choice B rationale:

A client who consistently has difficulty using utensils while eating is a concern for occupational therapy or speech therapy, but it is not an immediate priority. The client's difficulty with eating utensils can be addressed through therapeutic interventions within the rehabilitation setting.

Choice C rationale:

A client who has expressive aphasia requires a priority referral because this indicates potential communication difficulties that could hinder the client's ability to express needs, understand instructions, and participate in therapy. Expressive aphasia can impact the client's overall rehabilitation progress and safety.

Choice D rationale:

A client who consistently coughs after drinking liquids might require assessment and intervention, but it does not present an immediate priority. The nurse can address this concern within the rehabilitation unit and collaborate with the interdisciplinary team as needed.

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Correct Answer is D

Explanation

The correct answer is choiced. “I will wear gloves when changing the client’s hospital gown.”

Choice A rationale:

Cleaning reusable equipment with isopropyl alcohol is not effective against Clostridium difficile spores. Equipment should be cleaned with a sporicidal disinfectant to ensure the removal of C.difficile spores.

Choice B rationale:

Alcohol-based hand sanitizers are not effective against C. difficile spores.Hand hygiene should be performed with soap and water after contact with the client or their environment.

Choice C rationale:

Wearing a mask within 3 feet of the client is not necessary for C. difficile infection, as it is not transmitted via respiratory droplets.The primary mode of transmission is through contact with contaminated surfaces or feces.

Choice D rationale:

Wearing gloves when changing the client’s hospital gown is essential to prevent the transmission of C. difficile spores.Gloves should be worn for all contact with the client or their environment

A. Dishwashing gloves. B. Adhesive tape. C. Macadamia nuts. D. Bananas. E. Rubber bands.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

Dishwashing gloves are often made of latex, which can trigger an allergic reaction in individuals with a latex allergy. Direct contact with latex-containing items should be avoided to prevent allergic responses.

Choice B rationale:

Adhesive tape commonly contains latex and can lead to allergic reactions in individuals with a latex allergy. Avoiding contact with latex-containing items is crucial to prevent potential allergic symptoms.

Choice C rationale:

Macadamia nuts and bananas do not typically contain latex and are not known to trigger latex allergies. While these items can cause allergic reactions in some individuals, they are not relevant to a latex allergy.

Choice D rationale:

While macadamia nuts and bananas can cause allergies in some people, they do not contain latex and are not associated with latex allergies. Therefore, they are not items that the nurse needs to instruct the client to avoid due to their latex allergy.

Choice E rationale:

Rubber bands are often made from latex, which can provoke an allergic reaction in individuals with a latex allergy. Encouraging the client to steer clear of items like rubber bands helps prevent potential allergic responses.

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A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing transmission precautions with an assistive personnel (AP) who is providing care for a client who has a Clostridium difficile infection. Which of the following statements by the AP indicates an understanding of the teaching?

Correct Answer is D

Explanation

A home health nurse is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the nurse instruct the client to avoid? (Select all that apply.).

Correct Answer is ["A","B","E"]

Explanation

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