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.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Ambulation assistance is expected in rehabilitation. It reflects motor recovery needs but does not pose an immediate safety or health risk requiring urgent referral.
Choice B rationale: Difficulty using utensils indicates fine motor deficits. While important for occupational therapy, it’s not a priority compared to airway protection concerns.
Choice C rationale: Expressive aphasia affects communication but does not compromise physical safety or airway integrity. Speech therapy is appropriate but not urgent.
Choice D rationale: Coughing after drinking signals aspiration risk. This can lead to pneumonia or airway obstruction, requiring immediate referral to speech-language pathology for swallow evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.
Choice A rationale:
Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.
Choice B rationale:
Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.
Choice C rationale:
Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.
Choice D rationale:
Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.
Correct Answer is C
Explanation
The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”
Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.
Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.
Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.
Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.
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