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 C
No explanation
Correct Answer is A
Explanation
The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.
Other choices:
Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.
Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.
Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.
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