A nurse is caring for a client who has hemiparesis following a right-sided stroke. Which of the following actions should the nurse take?

Place objects within reach on the client's right side.

Encourage the client to repeat phonetic sounds.

Pause to allow the client time to respond to questions.

Frequently orient the client to time, place, and surroundings.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Placing objects within the client's reach on the right side helps to compensate for the hemiparesis and facilitates the client's ability to independently access items.

Choice B rationale:

Encouraging the client to repeat phonetic sounds might be more appropriate for speech therapy and may not directly address hemiparesis.

Choice C rationale:

Pausing to allow the client time to respond to questions is a communication technique but does not address the physical effects of hemiparesis.

Choice D rationale:

Frequently orienting the client to time, place, and surroundings is important for cognitive support but does not specifically address hemiparesis.

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Correct Answer is C

Explanation

Choice A rationale:

Newborns typically lose some weight after birth, but 15 percent loss would be excessive and concerning. A normal weight loss range is about 5 to 10 percent.

Choice B rationale:

Newborns should be fed on demand rather than adhering to strict schedules to ensure they are adequately nourished.

Choice C rationale:

Breastfeeding requires additional energy, and mothers are generally advised to consume around 500 extra calories a day to support milk production and their own energy needs.

Choice D rationale:

Offering a pacifier before sleep can reduce the risk of sudden infant death syndrome (SIDS), but this recommendation usually starts at around 1 to 2 months of age.

A. Absent deep tendon reflexes B. Fetal heart rate of 120/min C. Blood pressure 150/92 mm Hg D. Facial flushing

Correct Answer is A

Explanation

Choice A rationale:

Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.

Choice B rationale:

A fetal heart rate of 120/min is within a normal range and is not concerning.

Choice C rationale:

Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.

Choice D rationale:

Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.

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A nurse is caring for a client who has hemiparesis following a right-sided stroke. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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