A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?
Respiratory therapist
Occupational therapist
Physical therapist
Social worker
The Correct Answer is C
A. A respiratory therapist focuses on breathing and airway management, which is not the primary concern for a client needing strengthening after a stroke.
B. An occupational therapist helps clients with daily living activities and fine motor skills, but the focus on strengthening the affected side is more specific to physical therapy.
C. A physical therapist specializes in developing and implementing exercise programs to strengthen muscles and improve mobility, making this the most appropriate referral for the client's needs.
D. A social worker assists with emotional and social needs but would not focus on physical rehabilitation after a stroke.
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Correct Answer is ["B","C"]
Explanation
A. Clients with a basilar skull fracture may experience confusion or memory loss regarding the injury, making them unable to recall how it occurred.
B. Pooling of blood around the eyes, known as "raccoon eyes," is a common sign of a basilar skull fracture.
C. Bruising over the mastoid process (Battle's sign) is another classic sign of a basilar skull fracture, indicating trauma to the base of the skull.
D. Chvostek's sign is associated with hypocalcemia, not basilar skull fractures.
Correct Answer is ["C","D","E"]
Explanation
A. Restraints should not be used routinely for clients with seizure disorders, as they can lead to injury and are not recommended for seizure management.
B. A bite stick is not recommended during a seizure because it can cause injury to the client’s teeth and jaw.
C. Keeping an oxygen setup at the bedside is essential to provide supplemental oxygen if the client experiences difficulty breathing during or after a seizure.
D. Elevating the side rails when the client is in bed helps prevent falls and injuries during a seizure, providing a safer environment.
E. A suction setup at the bedside is important to clear secretions and prevent aspiration during a seizure, especially if the client has impaired swallowing or is at risk for aspiration.