NBCOT Registered Occupational Therapists (OTR) Quiz: Information Gathering

An occupational therapist in an early intervention program (birth to 3) is visiting the home of a 2-year-old with a diagnosis of Down syndrome. The mother reports that the child is a 'picky eater' and mealtimes are stressful. The referral notes concerns about oral motor skills. The therapist observes that the child eats a limited variety of pureed and soft mechanical foods and refuses most textured items.

To differentiate between a sensory-based feeding issue and an oral-motor skill deficit, which source of information would be MOST useful for the therapist to gather during the evaluation?

An OTR is evaluating a client in an acute care hospital who experienced an exacerbation of congestive heart failure (CHF). The client is medically stable and awaiting discharge to a subacute rehabilitation facility. The OTR needs to provide a recommendation regarding the appropriate level of care. During a brief ADL assessment, the client becomes short of breath after dressing their upper body and requires a 5-minute rest break. The client's oxygen saturation remained at 94% on 2L of oxygen via nasal cannula.

In addition to the observed ADL performance, which piece of information from the client's medical record is MOST critical for justifying the recommendation for subacute rehabilitation?

An occupational therapist in an outpatient orthopedic clinic is evaluating a 60-year-old client 10 days post-total hip arthroplasty (posterior approach). The client lives in a two-story home with a first-floor bathroom. The referral indicates the client should be weight-bearing as tolerated. The client reports pain is well-managed but expresses significant fear of falling, especially when using the stairs to get to their bedroom.

To complete a comprehensive discharge plan, which is the most critical piece of information the therapist needs to gather that is not typically included in a standard hospital discharge summary?

An occupational therapist is initiating an evaluation for a 55-year-old client in a work-hardening program. The client sustained a cumulative trauma injury to their dominant wrist while working on an assembly line and has been out of work for three months. A recent Functional Capacity Evaluation (FCE) indicates the client can lift up to 15 pounds occasionally, which is below the 25-pound requirement for their job. The client reports consistent pain at a level of 6/10 during activity.

To develop a work-hardening plan that is most relevant to the client's job, which information is essential for the therapist to obtain from the employer?

An occupational therapist is working with an interdisciplinary team at a palliative care unit. The client is a 68-year-old with end-stage amyotrophic lateral sclerosis (ALS). The client is now non-verbal and communicates using an eye-gaze device. The primary goal is to optimize quality of life and comfort. The team is considering seating and positioning options. The client's spouse is present and reports that the client appears increasingly agitated when left in their power wheelchair for more than an hour.

To best determine the source of the client's agitation and guide positioning recommendations, what is the therapist's MOST appropriate initial action?

An occupational therapist in a community mental health setting is assigned a new client, a 35-year-old veteran with PTSD, who is seeking help with returning to work. The client's self-report indicates difficulties with concentration, emotional regulation, and managing crowded environments. The referral paperwork from the Veterans Affairs (VA) hospital is limited to the diagnosis and a list of medications. The client has given consent for the therapist to contact the VA for more records.

To best understand the client's functional capabilities and formulate a relevant vocational rehabilitation plan, which specific VA record would provide the MOST valuable information?

An OTR in an outpatient hand therapy clinic receives a referral for a 30-year-old office worker who underwent a flexor tendon repair of the index finger (Zone II) four weeks ago. The referral from the surgeon includes the operative note and a prescription for a 'dorsal blocking splint and initiation of therapy.' During the interview, the client reports adherence to precautions but expresses extreme fear of re-rupturing the tendon, stating, 'I'm afraid to even look at my hand.'

To establish a safe and effective treatment plan, which piece of information is MOST critical for the therapist to obtain from the surgeon's operative note?

An occupational therapist in a public school is part of a team conducting a triennial re-evaluation for a fifth-grade student with a Section 504 Plan for ADHD. The student is passing all classes, but teachers report he is disorganized, frequently loses assignments, and has difficulty initiating tasks. The purpose of the re-evaluation is to determine if the student now requires specially designed instruction through an IEP.

To gather data that best differentiates between the need for continued accommodations under a 504 Plan versus eligibility for an IEP, which information source is most crucial?

An occupational therapist is preparing for the initial evaluation of a 6-year-old child in an outpatient pediatric clinic. The referral from the pediatrician notes concerns with 'sensory processing issues and poor fine motor skills.' The parents have provided a comprehensive developmental history questionnaire. The clinic has also received a large file from the child's preschool, which includes teacher observations, report cards, and some work samples.

To most effectively formulate a hypothesis about the relationship between the child's sensory processing and school-related fine motor tasks, which component of the provided records should the therapist prioritize for detailed review?

An OTR is evaluating an older adult client with a new diagnosis of low vision secondary to diabetic retinopathy. The client reports difficulty with medication management and meal preparation.

To understand the client's specific visual limitations, including acuity and visual field integrity, which report is ESSENTIAL for the OTR to review to guide the selection of appropriate assessments and interventions?

An OTR working in an acute care hospital is assigned to evaluate a 68-year-old patient who was admitted 12 hours ago following a total hip arthroplasty. The patient is stable and has been cleared by nursing for therapy evaluation.

What is the MOST important initial source of information for the OTR to consult to ensure patient safety and guide the evaluation?

A 79-year-old client is referred for a comprehensive driving evaluation by their physician due to family concerns about slowed reaction time and episodes of confusion.

In addition to the medical referral, which official document is MOST important for the occupational therapy driving rehabilitation specialist to obtain to verify the client's legal driving status?

A 58-year-old client who sustained a severe traumatic brain injury (TBI) is being transferred from an acute care hospital to an inpatient rehabilitation facility. The OTR is preparing for the initial evaluation upon the client's arrival.

What is the most effective way for the OTR to gather comprehensive information about the client's hospital course, medical complexities, and initial therapy assessments to ensure continuity of care?

A 45-year-old mechanic is referred to a work hardening program following a rotator cuff repair. The client has been cleared by the surgeon to begin graded, simulated work activities.

To design an effective, client-centered work hardening program, what is the MOST critical piece of information the OTR needs to obtain?

An occupational therapist is conducting an initial home visit for a 20-month-old toddler referred to an early intervention program due to concerns about play skills and social interaction.

Which method of information gathering is MOST appropriate for initiating the occupational profile in this family-centered context?

An OTR is preparing to meet a 30-year-old client admitted to an acute inpatient psychiatric unit. The admission was precipitated by an acute psychotic episode.

To ensure personal and patient safety and to understand the immediate precipitants of the crisis, what is the MOST critical initial source of information for the OTR to review?

An OTR is part of a team developing an Individualized Education Program (IEP) with a transition plan for a 17-year-old student with a specific learning disability. The student has expressed interest in working with animals.

To gather relevant, age-appropriate information about the student's vocational aptitudes and interests to inform the transition plan, which source is MOST appropriate to utilize?

An OTR receives an urgent consultation for a patient in the emergency department who was found unconscious at home. The patient is now awake but is a poor historian due to confusion. No family or friends are present.

What is the OTR's MOST effective initial action to attempt to gather information about the patient's likely prior level of function?

An OTR is scheduled to begin training with a client who was recently fitted with a new myoelectric transradial (below-elbow) prosthesis.

To provide effective initial client education and training, what information is MOST important for the OTR to obtain from the prosthetist?

An occupational therapist in a home health agency is scheduled for an initial evaluation with an 82-year-old client who was just discharged from a skilled nursing facility (SNF) after a 3-week stay for rehabilitation following a fall.

Which source of information is MOST crucial for the OTR to review to understand the client's recent progress, current functional status, and recommendations for carryover at home?