A patient is hospitalized poststroke. The nurse approaches the patient from the patient's left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse's presence or voice. Which action should the nurse take first?
Walk to the other side of the bed and try again.
Wave a hand in front of the patient's face.
Speak more loudly and clearly.
Use a picture board to explain to the patient what the nurse is going to do.
The Correct Answer is A
A. Walk to the other side of the bed and try again: The patient may have right-sided neglect due to the stroke, meaning they are not aware of stimuli on the left side. Approaching from the other side where the patient has better perception might help them respond better.
B. Wave a hand in front of the patient's face: This might not be effective and can startle the patient. It does not address the underlying issue of spatial neglect.
C. Speak more loudly and clearly: There is no indication that the patient has hearing loss or language comprehension issues. Speaking louder may not be effective if the patient is experiencing spatial neglect.
D. Use a picture board to explain to the patient what the nurse is going to do: This is a good strategy for communication but does not address the immediate need to reposition to a more effective approach to gain the patient’s attention first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The amount of pressure exerted by the veins and arteries on the heart.: This is not accurate. Blood pressure specifically measures the force exerted by blood on the walls of arteries, not veins, and not the pressure they exert on the heart.
B. The amount of blood volume within the blood vessels.: This is incorrect. Blood pressure is related to blood volume, but it specifically measures the force against the arterial walls.
C. The amount of resistance within the veins during heart contraction.: Blood pressure refers to arterial pressure, not venous resistance.
D. The amount of force being placed on arteries by blood.: This is correct. Blood pressure measures the force of blood pushing against the walls of the arteries as the heart pumps blood through the circulatory system.
Correct Answer is A
Explanation
Correct answer: A
A. The right leg for shortening: This is the most critical observation because crossing the legs after a hip replacement can cause hip dislocation. A shortened leg can be a sign of dislocation, which is a serious complication that requires immediate attention.
B. The left leg for internal rotation: Internal rotation is more of a concern for the operated leg (the right leg), not the left leg, in this context.
C. The left leg for loss of function: This is less relevant unless there is concern about a complication in the left leg, which is not directly related to the issue of crossing legs post-surgery.
D. The right knee for crepitation: Crepitation refers to a crackling sound and is more associated with joint issues rather than an indicator of hip dislocation.
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