A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

Encouraging the client to use a cane as needed for mobility

Encouraging the client to use their right hand for daily activities

Encouraging the client to consume a soft diet and thickened liquids

Encouraging the client to complete all activities of daily living (ADLs) independently

Answer and Explanation

The Correct Answer is A

A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

 Sepsis: The client's low CD4 count indicates a weakened immune system, making them susceptible to infections. The presence of fever, cough, and other symptoms suggests a potential infection, which can lead to sepsis if not treated promptly.

 Malnutrition: The client's weight loss, diarrhea, anorexia, and difficulty eating are all signs of malnutrition. A compromised immune system can also contribute to malnutrition.

A. "I developed a hematoma because an artery burst in my brain when my head hit the windshield." B. "I developed a bleed in my brain because my platelets were too high." C. "I developed a hematoma because I take a blood thinner and my head hit the windshield." D. "I developed a hematoma because my bleeding times were too low and I hit my head."

Correct Answer is C

Explanation

A. A subdural hematoma is typically caused by venous bleeding, not arterial bleeding. An arterial rupture would more likely cause an epidural hematoma, which is not the case here.
B. High platelet counts are not commonly associated with the formation of subdural hematomas. Subdural hematomas are usually due to bleeding related to anticoagulant use or trauma.
C. Taking a blood thinner like warfarin increases the risk of bleeding and hematoma formation, particularly when combined with head trauma. This statement correctly links the anticoagulant therapy and head injury as contributing factors to the subdural hematoma.
D. Low bleeding times are not a cause of hematomas. In fact, elevated bleeding times due to anticoagulant therapy would increase the risk of bleeding, not low bleeding times.

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A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 43-year-old client who has human immunodeficiency virus (HIV). Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown and dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Correct Answer is C

Explanation

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