A client has little use of the left side due to a stroke. To assist with ambulation for the first time, the nurse should walk:
directly in front of the client.
along the affected left side.
directly behind the client.
along the unaffected right side.
The Correct Answer is B
Choice A reason: This is incorrect. Walking directly in front of the client may block their view and increase their risk of falling. The nurse should walk to the side and slightly behind the client to provide support and guidance³.
Choice B reason: This is correct. Walking along the affected left side allows the nurse to assist the client with balance, weight shifting, and foot clearance. The nurse should also encourage the client to use the handrail on their strong side³.
Choice C reason: This is incorrect. Walking directly behind the client may not allow the nurse to see the client's gait pattern or intervene quickly if the client loses balance. The nurse should walk to the side and slightly behind the client to monitor and assist them³.
Choice D reason: This is incorrect. Walking along the unaffected right side may not provide adequate support or protection for the client's affected side. The nurse should walk along the affected left side to help the client with their hemiplegic gait³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Admission blood pressure is 110/70 is not the information that the nurse must report to the health care provider prior to the procedure. This is a normal blood pressure reading for an adult client and does not indicate any contraindication or complication for the cardiac angiogram.
Choice B reason: Client has multiple food and drug allergies is the information that the nurse must report to the health care provider prior to the procedure. This is a critical information that may affect the choice of contrast agent, medications, or equipment used for the cardiac angiogram. The nurse should identify the specific allergens and the type and severity of the allergic reactions that the client has experienced in the past.
Choice C reason: Pedal pulses are 1+ bilaterally is not the information that the nurse must report to the health care provider prior to the procedure. This is a low-normal finding for the strength of the peripheral pulses and does not indicate any significant vascular impairment or obstruction. The nurse should document and monitor the pedal pulses, but not necessarily report them.
Choice D reason: Client is slightly anxious is not the information that the nurse must report to the health care provider prior to the procedure. This is a common and expected emotional response for a client who is undergoing an invasive diagnostic test and does not require any immediate intervention. The nurse should provide reassurance and education to the client and address any concerns or questions that they may have.
Correct Answer is D
Explanation
Choice A reason: Furosemide 40 mg PO daily is not the medication that the nurse should administer for chest pain. Furosemide is a diuretic that reduces fluid volume and lowers blood pressure, but it does not relieve anginal pain.
Choice B reason: Diltiazem 30 mg PO daily is not the medication that the nurse should administer for chest pain. Diltiazem is a calcium channel blocker that relaxes the blood vessels and lowers blood pressure, but it does not act quickly enough to relieve acute anginal pain.
Choice C reason: Metoprolol 25 mg PO bid is not the medication that the nurse should administer for chest pain. Metoprolol is a beta blocker that slows down the heart rate and lowers blood pressure, but it does not act quickly enough to relieve acute anginal pain.
Choice D reason: Nitroglycerin 0.4 mg SL PRN is the medication that the nurse should administer for chest pain. Nitroglycerin is a nitrate that dilates the coronary arteries and increases blood flow to the heart, thus relieving anginal pain. It is given sublingually (under the tongue) as needed for chest pain.
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