A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
Orientation to person and place only.
Unequal bilateral hand grip strengths.
Left-sided facial drooping and dysphagia.
Pupillary changes to ipsilateral dilation.
The Correct Answer is D
Choice A reason: Orientation to person and place only suggests confusion, common in right hemisphere stroke affecting non-dominant cognition. This is not immediately life-threatening. Pupillary dilation indicates increased intracranial pressure (ICP) or herniation, a critical emergency requiring urgent intervention to prevent brain stem damage or death.
Choice B reason: Unequal hand grip strengths indicate hemiparesis, typical in right hemisphere stroke affecting left-sided motor function. This is expected and not acutely life-threatening. Pupillary dilation signals rising ICP or herniation, necessitating immediate intervention to prevent catastrophic neurological decline, making it the priority finding.
Choice C reason: Left-sided facial drooping and dysphagia are common in right hemisphere stroke, reflecting contralateral cranial nerve deficits. These are serious but not immediately life-threatening. Pupillary dilation indicates potential herniation from ICP, requiring urgent intervention like mannitol to prevent brain stem compression and fatal outcomes.
Choice D reason: Ipsilateral pupillary dilation in right hemisphere stroke signals increased ICP or herniation, compressing the oculomotor nerve (CN III), impairing pupillary constriction. This life-threatening emergency indicates impending brain stem compromise, requiring immediate intervention with ICP-lowering measures or surgery to prevent irreversible damage or death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.
Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.
Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.
Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.
Correct Answer is C
Explanation
Choice A reason: Influenza immunization is unlikely to cause eczema flare-ups, as it targets systemic immunity, not skin allergens. A new dog’s dander is a common trigger, making pet exposure more relevant, per dermatological assessment and eczema management protocols in nursing care.
Choice B reason: Corticosteroid cream treats eczema, reducing flare-ups, not causing them. A new dog’s dander is a likely allergen triggering symptoms. Cream use is therapeutic, per dermatological treatment and eczema exacerbation assessment standards in nursing practice during home visits.
Choice C reason: A grandson’s new pet dog introduces allergens like dander, a common eczema trigger, explaining the recent flare-up. Identifying environmental exposures is critical for pinpointing causes, guiding avoidance strategies, per eczema management and dermatological assessment protocols in nursing care.
Choice D reason: A friend with eczema is unlikely to trigger flare-ups, as eczema is not contagious. A new dog’s dander is a more probable allergen. Social contact is less relevant, per dermatological assessment and eczema trigger identification standards in nursing practice.
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