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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Option A. Instruct the client to void, because this reduces the risk of bladder injury during the procedure. The other options are incorrect because they are not necessary or appropriate for a paracentesis.
Option B, position the client on their left side, is incorrect because the client should be positioned upright or semi-Fowler's to allow gravity to assist with fluid drainage.
Option C, insert an IV catheter, is incorrect because an IV catheter is not required for a paracentesis unless the client needs fluid replacement or medication administration.
Option D, prepare the client for moderate (conscious) sedation, is incorrect because a paracentesis is usually performed under local anesthesia and does not require sedation
Correct Answer is A
Explanation
- A. Correct. A hemoglobin level of 14.9 g/dL indicates that the client has an adequate amount of oxygen-carrying capacity in the blood, which is the goal of blood transfusion therapy.
- B. Incorrect. A WBC count of 12,000/mm3 is slightly elevated and may indicate an infection or inflammation, which are not related to blood transfusion therapy.
- C. Incorrect. A potassium level of 48 mEq/L is dangerously high and may cause cardiac arrhythmias, muscle weakness, or paralysis. This is not an expected outcome of blood transfusion therapy and may indicate hemolysis or renal impairment.
- D. Incorrect. A BUN level of 18 mg/dL is within the normal range and does not reflect the effectiveness of blood transfusion therapy.
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