A nurse caring for a client who has developed homonymous hemianopia affecting their left visual field after a stroke. Which of the following interventions is appropriate for this client?

Have the client wear sunglasses

Encourage the client to scan the room from left to right

Apply ointment to the client’s eyes

Teach client to scan the room from right to left

Answer and Explanation

The Correct Answer is D

Choice A reason: Wearing sunglasses is not an appropriate intervention for homonymous hemianopia, a visual field defect from stroke affecting the same side of both eyes. Sunglasses may reduce glare but do not address the loss of left visual field or help compensate for the neurological deficit.

Choice B reason: Scanning from left to right is incorrect for left homonymous hemianopia. This would prioritize the intact right visual field, neglecting the affected left side. Clients need to scan toward the affected side (right to left) to compensate for the visual loss and ensure awareness of their environment.

Choice C reason: Applying eye ointment is irrelevant for homonymous hemianopia, which results from brain damage (e.g., occipital lobe stroke) rather than ocular issues. Ointment may treat dry eyes or infections but does not address the neurological visual field defect caused by disrupted visual pathways.

Choice D reason: Teaching the client to scan from right to left is appropriate for left homonymous hemianopia. This compensates for the lost left visual field by training the client to actively turn their head toward the affected side, improving awareness of their environment and reducing collision risks.

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Correct Answer is D

Explanation

Choice A reason: Pain relief after the fourth nitroglycerin dose does not confirm myocardial infarction with cardiac tissue injury. While nitroglycerin relieves angina by dilating coronary arteries, persistent pain despite treatment suggests MI. ST-segment elevation on EKG is a more definitive indicator of acute myocardial injury.

Choice B reason: Positive urine cultures indicate a urinary tract infection, unrelated to myocardial infarction or cardiac tissue injury. MI is diagnosed via EKG changes (e.g., ST elevation) and biomarkers like troponin, reflecting myocardial ischemia, not systemic infections, which do not cause chest pain or cardiac damage.

Choice C reason: Normal troponin levels do not support a diagnosis of myocardial infarction with cardiac tissue injury. Troponin rises within hours of myocardial damage due to cell death. ST-segment elevation on EKG is a more immediate indicator of acute MI, preceding troponin elevation in early presentation.

Choice D reason: ST-segment elevation on a 12-lead EKG is a hallmark of myocardial infarction with cardiac tissue injury, indicating transmural ischemia due to coronary artery occlusion. This electrical change reflects acute myocardial damage, prompting urgent intervention like cardiac catheterization to restore blood flow and limit infarction size.

A. Count your pulse for 60 seconds at the same time each day B. Do not have a microwave oven in the home C. Notify airport security of your pacemaker when traveling D. Resume physical activities that can cause bumping or jolting E. Avoid wearing tight clothing over the insertion area

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Counting the pulse for 60 seconds daily helps monitor pacemaker function, ensuring it maintains the prescribed heart rate. This allows early detection of device malfunction, such as failure to pace, which could lead to bradycardia or inadequate cardiac output, supporting safe post-implantation care.

Choice B reason: Avoiding a microwave oven in the home is unnecessary, as modern pacemakers are shielded against electromagnetic interference from household appliances. This outdated restriction does not apply, and clients can safely use microwaves without risking device malfunction, making this instruction incorrect for pacemaker care.

Choice C reason: Notifying airport security of the pacemaker is essential, as metal detectors may trigger alerts, and security wands could interfere with device function. Informing security ensures safe screening methods (e.g., pat-downs) are used, preventing potential pacemaker disruption and ensuring safe travel for the client.

Choice D reason: Resuming physical activities that cause bumping or jolting should be avoided, as they risk dislodging pacemaker leads or damaging the device, especially early post-implantation. Such activities could cause lead displacement, leading to ineffective pacing or arrhythmias, making this an inappropriate instruction.

Choice E reason: Avoiding tight clothing over the insertion area is correct, as it prevents pressure on the pacemaker site, reducing irritation, infection risk, or lead dislodgement. Loose clothing promotes healing and device stability, ensuring proper function and comfort during the post-implantation recovery period.

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A nurse caring for a client who has developed homonymous hemianopia affecting their left visual field after a stroke. Which of the following interventions is appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client was brought to the emergency department for severe chest pain despite nitroglycerin and aspirin administration in the ambulance. Which of the following findings would suggest myocardial infarction (MI) with cardiac tissue injury?

Correct Answer is D

Explanation

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply)

Correct Answer is ["A","C","E"]

Explanation

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