A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?
A change in pupil size
Difficulty speaking
Inability to follow direction
Right-sided weakness
The Correct Answer is A
A change in pupil size can indicate an increase in intracranial pressure, which can lead to a life-threatening situation. The nurse should immediately report this finding to the provider.
Choice B is incorrect because difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice C is incorrect because inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice D is incorrect because right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice B: Difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice C: Inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice D: Right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D, Describe the food placement as though the plate were a clock. When delivering the client's meal tray, the nurse should describe the food placement as though the plate were a clock to help the client know where the food is located. This helps the client be more independent and participate actively at mealtime. Choice A is incorrect because arranging for assistive personnel to feed the client may take away the client's independence. Choice B is incorrect because discouraging conversations during the client's mealtime may make the client feel isolated. Choice C is incorrect because providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
Other choices:
A. Arrange for assistive personnel to feed the client: Arranging for assistive personnel to feed the client may take away the client's independence.
B. Discourage conversations during the client's mealtime: Discouraging conversations during the client's mealtime may make the client feel isolated.
B. Provide the client with small-handled adaptive utensils: Providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
Correct Answer is C
Explanation
The correct answer is choice C. Place white tape on the edges of stairs.
Choice A rationale:
While having the furnace inspected is important for safety, it should be done annually, not every two years.Regular inspections help prevent carbon monoxide leaks and ensure the furnace is functioning properly.
Choice B rationale:
Running wires and cords under carpeting is a safety hazard. It can lead to overheating and potentially cause a fire.Additionally, it creates a tripping hazard.
Choice C rationale:
Placing white tape on the edges of stairs is a recommended safety measure.It increases visibility, especially for older adults who may have vision impairments, reducing the risk of falls.
Choice D rationale:
Placing area rugs on wooden floors can be dangerous as they can slip and cause falls.If area rugs are used, they should be secured with non-slip backing or tape.
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