A nurse is planning care for a client who has left-sided hemiplegia following a stroke.
Which of the following actions should the nurse include in the plan of care?
Provide the client with a short-handled reacher.
Place a plate guard on the client's meal tray.
Remind the client to use a cane on his left side while ambulating.
Position the bedside table on the client's left side.
The Correct Answer is A
The nurse should provide the client with a short-handled teacher.
This can help the client to reach and grasp objects without having to overextend or strain their unaffected arm.
Choice B is also correct.
The nurse should place a plate guard on the client’s meal tray.
This can help prevent food from spilling off the plate and make it easier for the client to eat with one hand.
Choice C is wrong because reminding the client to use a cane on his left side while ambulating could be unsafe as the client’s left side is affected by hemiplegia.
Choice D is wrong because positioning the bedside table on the client’s left side could make it difficult for the client to reach items on the table.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process.
The presence of dark red granulation tissue is a sign that the wound is healing.
B.Light yellow exudate: Light yellow exudate may indicate the presence of infection and is not a sign of healing.
C. Dry brown eschar: Dry brown eschar is dead tissue that needs to be removed for the wound to heal properly.
D.Wound tissue firm to palpation: Wound tissue firm to palpation is not a specific sign of healing.
Correct Answer is C
Explanation
Furosemide is a loop diuretic that can cause loss of potassium from the body.
A potassium level of.2 mEq/L is considered low (hypokalemia) and can be a contraindication for receiving the medication.
Sodium 136 mEq/L is within the normal range and is not a contraindication for receiving furosemide.
B) Creatinine 0.8 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
D) BUN 18 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
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