A male client is admitted to the stroke rehabilitation unit and is demonstrating right homonymous hemianopsia. The practical nurse (PN) observes that the client only eats the foods on the left side of the plate and tray. Which is the best action for the PN to use with this client to compensate for the visual field deficit?

Place the food and utensils in the client's left visual field and leave him alone.

Feed the client foods that are on the right side of his visual field.

Remind the client to look all over the tray to view and eat all the foods provided.

Prompt the client to rotate his plate to see foods on the right side of the tray.

Answer and Explanation

The Correct Answer is C

Choice A reason: Placing the food and utensils in the client's left visual field and leaving him alone does not address the underlying issue of the visual field deficit. While it may temporarily solve the problem of the client eating only the food on the left side, it does not encourage the client to adapt to or compensate for the right homonymous hemianopsia. The goal of rehabilitation is to help the client develop strategies to manage their condition independently, and this approach does not foster such skills.
Choice B reason: Feeding the client foods that are on the right side of his visual field is not the most effective approach, as it does not promote the client's independence or help them adapt to their visual field deficit. While it ensures the client consumes the food on the right side, it does not teach the client to compensate for their hemianopsia, which is an essential aspect of their rehabilitation.
Choice C reason: Reminding the client to look all over the tray to view and eat all the foods provided is the best approach. This action helps the client become more aware of their visual field deficit and encourages them to develop the habit of scanning their environment. Teaching the client to consistently look around their entire visual field promotes independence and helps them adapt to daily activities despite their condition. This strategy supports the goal of rehabilitation, which is to enhance the client's ability to manage their visual impairment independently.
Choice D reason: Prompting the client to rotate his plate to see foods on the right side of the tray is a practical solution, but it does not address the broader need for the client to learn to scan their environment. While rotating the plate may temporarily help the client access the food on the right side, it does not encourage the development of compensatory strategies for the visual field deficit. Encouraging the client to look all over the tray is a more effective approach for long-term adaptation and independence.

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Correct Answer is A

Explanation

Choice A reason: A blood pressure measurement of 80/60 mm Hg is significantly low and may indicate hypotension, which can lead to symptoms such as dizziness, fainting, or shock. This requires immediate action to assess and manage the client's condition to prevent complications.
Choice B reason: A blood pressure measurement of 140/90 mm Hg indicates hypertension, which is a concern but does not require immediate emergency intervention. It requires follow-up and management to prevent long-term health issues.
Choice C reason: A blood pressure measurement of 130/85 mm Hg is considered elevated but not critically high. It is important to monitor and manage, but it does not require immediate emergency action.
Choice D reason: A blood pressure measurement of 120/90 mm Hg is slightly elevated diastolic pressure but not critically so. It is important to monitor, but it does not necessitate immediate emergency intervention.

A. Neuro vital signs. B. Urinary output. C. Blood pressure. D. Breath sounds.

Correct Answer is D

Explanation

Choice A reason: Evaluating neuro vital signs includes assessing the client's level of consciousness, pupil response, motor function, and other neurological indicators. While important for overall assessment, changes in neurological status are not the most immediate concern in the context of heart failure and the client's request for more pillows. The request may be related to orthopnea, a common symptom of heart failure where clients experience difficulty breathing while lying flat.
Choice B reason: Monitoring urinary output is crucial for assessing kidney function and fluid balance, especially in clients with heart failure. However, it does not directly address the client's symptom of needing more pillows to sleep, which is more likely related to respiratory discomfort. While maintaining adequate urinary output is important, it is not the primary assessment needed in this scenario.
Choice C reason: Blood pressure is a vital sign that needs regular monitoring in clients with heart failure, as it can indicate fluid status and cardiac function. However, the need for additional pillows to sleep is more directly related to respiratory issues rather than blood pressure alone. While important, it is not the primary focus in response to the client's specific request.
Choice D reason: Evaluating breath sounds is the most relevant assessment when a client with heart failure requests more pillows to sleep. This request often indicates orthopnea, where the client has difficulty breathing while lying flat due to fluid accumulation in the lungs (pulmonary congestion). By assessing breath sounds, the PN can detect signs of crackles, wheezing, or decreased air entry, which may indicate worsening heart failure or pulmonary edema. Prompt assessment and intervention are crucial to address respiratory distress and prevent further complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assisting with blood pressure measurement for adults at a community health fair. Which blood pressure measurement requires the most immediate action by the PN?

Correct Answer is A

Explanation

A client with heart failure requests two more pillows to sleep with at night. Which area should the practical nurse (PN) evaluate when responding to the client's request?

Correct Answer is D

Explanation

The practical nurse (PN) is assigned to care for a client with Guillain-Barré syndrome (GBS). Which problem has the highest priority for this client's care?

The practical nurse (PN) is caring for a client who has a fractured right tibia and fibula. To reduce swelling and promote comfort, the PN should place the client in which position?

A client with Crohn's disease has a serum sodium level of 130 mEq/L (130 mmol/L). Which foods should the practical nurse (PN) encourage the client to eat? Reference Range: Sodium: 136 to 145 mEq/L (136 to 145 mmol/L)

A client who received a renal transplant two weeks ago is experiencing a rapid and sudden decrease in urine output in the catheter. Which assessment(s) should the practical nurse (PN) complete before notifying the charge nurse? Select all that apply.

Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?

A client with breast cancer who received chemotherapy two weeks ago returns to the clinic for follow-up. Which priority follow-up assessment should the practical nurse (PN) anticipate for this client?

When obtaining a fingerstick blood sugar, the practical nurse (PN) uses the lancet to prick the client's finger. After observing that a drop of blood is visible on the finger, which action should the PN take?

The practical nurse (PN) is preparing a client for a mammogram. Which instruction should the PN provide the client?