A nurse is collecting data from a client who is recovering from a recent stroke.
Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

Coughing while eating.

Fine motor tremors.

Facial flushing.

Urinary incontinence.

Answer and Explanation

The Correct Answer is A

Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.

Choice B is wrong because fine motor tremors are not related to speech or language problems.

They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.

Choice C is wrong because facial flushing is not related to speech or language problems.

It may be caused by high blood pressure, fever, anxiety or other conditions.

Choice D is wrong because urinary incontinence is not related to speech or language problems.

It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.

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Correct Answer is A

Explanation

Muscle irritability. A client with a lithium level of

2.0 mEq/L has severe lithium toxicity, which can cause muscle irritability, tremors, seizures, and other neurological symptoms. The normal therapeutic range for lithium is 0.8-1.2 mEq/L.

Choice B is wrong because constipation is not a sign of lithium toxicity, but rather a possible side effect of lithium therapy at lower doses.

Choice C is wrong because hypoglycemia is not a sign of lithium toxicity, but rather a possible complication of diabetes or other conditions that affect blood sugar levels.

Choice D is wrong because increased blood pressure is not a sign of lithium toxicity, but rather a possible risk factor for cardiovascular disease or other conditions that affect blood vessels.

A. Suggest that the client wear facility clothing until the prosthesis fitting. B. Encourage the client to visit with someone who has had an amputation. C. Discourage the client from touching the residual limb for the first week. D. Reassure the client that the rehabilitation program is optional.

Correct Answer is B

Explanation

Encourage the client to visit with someone who has had an amputation.

This strategy can help the client cope with the loss of a body part and learn from the experience of others who have gone through a similar situation.

Choice A is wrong because suggesting that the client wear facility clothing until the prosthesis fitting can delay the client’s acceptance of the body image alteration and increase the risk of infection.

Choice C is wrong because discouraging the client from touching the residual limb for the first week can interfere with the healing process and prevent the client from becoming familiar with the new body part.

Choice D is wrong because reassuring the client that the rehabilitation program is optional can discourage the client from participating in physical therapy and hinder the recovery and adaptation.

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A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who is postoperative following a below-the-knee amputation. Which of the following strategies should the nurse include to help the client progress toward acceptance of this body image alteration?

Correct Answer is B

Explanation

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A nurse is collecting data from a client who is recovering from a recent stroke.
Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?