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 A
Explanation
A. TIA: A transient ischemic attack (TIA) is characterized by temporary symptoms due to a brief period of reduced blood flow to the brain, with no lasting damage.
B. Stroke: A stroke involves a more prolonged interruption of blood flow to the brain and typically results in permanent neurological damage.
C. CVA: Cerebrovascular accident (CVA) is another term for stroke, involving sustained damage.
D. OSAH: This is not a relevant term or acronym for the condition described. It is not related to cerebral circulation impairment.
Correct Answer is B
Explanation
A. Keep affected body areas covered at all times: While keeping warm can help prevent attacks, it is not practical or necessary to cover the areas all the time, especially in warmer environments.
B. Avoid stimulation that causes vasoconstriction: Raynaud disease is triggered by factors that cause vasoconstriction, such as exposure to cold or stress. Avoiding these triggers is key to preventing attacks.
C. Get plenty of outdoor exercise all year: Exercise is beneficial for general health but exposure to cold during outdoor activities can trigger Raynaud's attacks, especially in cold weather.
D. Take vasopressors to prevent exacerbation of symptoms: Vasopressors cause vasoconstriction and would likely worsen Raynaud's symptoms rather than preventing them.
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