A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?
Impaired sense of humor
Poor judgment
Intellectual impairment
Loss of depth perception
The Correct Answer is C
Choice A reason: Impaired sense of humor is not a common finding for a client who had a stroke involving the left cerebral hemisphere. Impaired sense of humor is more likely to occur after a stroke involving the right cerebral hemisphere, which is responsible for processing humor, irony, and sarcasm.
Choice B reason: Poor judgment is not a typical finding for a client who had a stroke involving the left cerebral hemisphere. Poor judgment is more likely to occur after a stroke involving the frontal lobe, which is involved in executive functions, such as planning, reasoning, and decision making.
Choice C reason: Intellectual impairment is a possible finding for a client who had a stroke involving the left cerebral hemisphere. The left cerebral hemisphere is dominant for language and analytical thinking in most people. A stroke affecting this hemisphere can impair the ability to speak, read, write, calculate, and comprehend information.
Choice D reason: Loss of depth perception is not a frequent finding for a client who had a stroke involving the left cerebral hemisphere. Loss of depth perception is more likely to occur after a stroke involving the occipital lobe, which is involved in visual processing, or the parietal lobe, which is involved in spatial awareness.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Choice A reason: Difficulty moving the upper extremities is not a complication of immobility, but a result of the stroke. A stroke can damage the part of the brain that controls movement, sensation, or coordination of the limbs, causing hemiparesis (weakness) or hemiplegia (paralysis) on one side of the body. The nurse should assist the client with passive or active range of motion exercises to prevent muscle atrophy and contractures.
Choice B reason: Stiffness in the lower extremities is not a complication of immobility, but a result of the stroke. A stroke can affect the muscle tone of the limbs, causing spasticity (increased muscle tension) or flaccidity (decreased muscle tone) on one side of the body. The nurse should apply splints or braces to prevent deformities and provide massage or stretching to relieve stiffness.
Choice C reason: A reddened area over the sacrum is a complication of immobility, and a sign of a pressure injury. A pressure injury is a localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear. The sacrum is a common site for pressure injuries, as it is a bony prominence that bears the weight of the body when lying down. The nurse should reposition the client every 12 hours, provide skin care, and use pressure relieving devices to prevent pressure injuries.
Choice D reason: Difficulty hearing some types of sounds is not a complication of immobility, but a result of aging or other factors. Hearing loss can occur due to various causes, such as exposure to loud noise, ear infections, earwax buildup, or ototoxic medications. The nurse should assess the client's hearing and use communication strategies, such as speaking clearly, facing the client, and reducing background noise.
Correct Answer is D
Explanation
Choice A reason: Narrowed pulse pressure is not a specific manifestation of pneumonia in the older adult client. Pulse pressure is the difference between the systolic and diastolic blood pressure readings. A normal pulse pressure is about 40 mm Hg, and a narrowed pulse pressure is less than 25 mm Hg. A narrowed pulse pressure can indicate various conditions, such as heart failure, shock, or aortic stenosis, but it is not a sign of pneumonia.
Choice B reason: Night sweats are not a common manifestation of pneumonia in the older adult client. Night sweats are episodes of excessive sweating during sleep that can soak the bedding or clothing. Night sweats can have many causes, such as menopause, infections, medications, or cancer, but they are not typically associated with pneumonia.
Choice C reason: Bradycardia is not a usual manifestation of pneumonia in the older adult client. Bradycardia is a slow heart rate, defined as less than 60 beats per minute. Bradycardia can be normal in some people, such as athletes or those who are very fit, or it can be a sign of a problem with the heart's electrical system. Pneumonia does not cause bradycardia, but it can cause tachycardia, which is a fast heart rate, due to the increased oxygen demand and inflammation.
Choice D reason: Confusion is a frequent manifestation of pneumonia in the older adult client. Confusion is a state of impaired awareness, orientation, memory, or judgment. Confusion can occur in older adults with pneumonia due to several factors, such as hypoxia, dehydration, electrolyte imbalance, fever, or infection. Confusion can also increase the risk of complications, such as aspiration, falls, or delirium. Therefore, the nurse should monitor the mental status of the older adult client with pneumonia and report any changes to the provider..
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