A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
Diminished hand-to-mouth coordination
Impaired voluntary cough
Altered level of consciousness
Unilateral ptosis
The Correct Answer is B
Choice A reason: Diminished hand-to-mouth coordination is not a finding that requires a referral to speech-language pathology, as it is related to the motor function of the upper extremities. The nurse should refer the client to physical therapy or occupational therapy for this issue.
Choice B reason: Impaired voluntary cough is a finding that requires a referral to speech-language pathology, as it indicates a possible dysfunction of the swallowing mechanism or the vocal cords. The nurse should refer the client to speech-language pathology for a swallowing evaluation and intervention.
Choice C reason: Altered level of consciousness is not a finding that requires a referral to speech-language pathology, as it is related to the neurological function of the brain. The nurse should monitor the client's Glasgow Coma Scale score and report any changes to the provider.
Choice D reason: Unilateral ptosis is not a finding that requires a referral to speech-language pathology, as it is related to the cranial nerve function of the eye. The nurse should assess the client's pupillary response and eye movements and report any abnormalities to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not the correct choice because low pain tolerance is not the most urgent issue to address. The client may experience some pain and discomfort after the surgery, but this can be managed with medication and non-pharmacological interventions. The nurse should educate the client on how to use pain scales, request pain relief, and apply ice packs or heat pads as needed.
Choice B reason: This is not the correct choice because decreased self-esteem is not the most urgent issue to address. The client may have some negative feelings about their appearance or abilities after the surgery, but this can be improved with counseling and support groups. The nurse should encourage the client to express their emotions, focus on their strengths, and seek professional help if necessary.
Choice C reason: This is not the correct choice because limited social support is not the most urgent issue to address. The client may have difficulty coping with the recovery process and the lifestyle changes required after the surgery, but this can be alleviated with community resources and referrals. The nurse should assess the client's social network, provide information on local agencies and organizations, and arrange for home health care or visiting nurses if needed.
Choice D reason: This is the correct choice because inadequate food supply is the most urgent issue to address. The client needs to have access to nutritious and balanced meals to promote healing and prevent complications after the surgery. The nurse should evaluate the client's food security, provide food vouchers or coupons, and connect the client with food banks or meal delivery services.
Correct Answer is B
Explanation
Choice A reason: The client's electrical cord is taped to the floor is not a safety hazard, but rather a safety measure to prevent tripping or pulling the cord.
Choice B reason: The client's bedside lamp is plugged in using an extension cord with two prongs is a safety hazard because it poses a risk of fire or electric shock. Extension cords should have three prongs and should not be used for permanent wiring.
Choice C reason: The client has used tacks to secure the carpet on the stairs is not a safety hazard, but rather a safety measure to prevent slipping or falling on the stairs.
Choice D reason: The client stores cleaning supplies in a locked cabinet above his head is not a safety hazard, but rather a safety measure to prevent accidental ingestion or exposure to toxic substances.
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