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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Correct answer: A
A. Monitoring for infection: Infection is a significant risk with external fixation devices due to the presence of pins that penetrate the skin and soft tissues. Monitoring for signs of infection, such as redness, swelling, discharge, or increased pain, is crucial.
B. Monitoring circulatory status: While circulatory status is important, especially in cases of limb injury or immobilization, it is not the most immediate concern compared to the risk of infection from the external fixation device.
C. Validating proper mobility: Ensuring proper mobility is important, but it is secondary to the prevention and detection of infection. Mobility assessments can be done after confirming that there are no infections or complications.
D. Checking discomfort level: While assessing discomfort is important for pain management and comfort, it is not as critical as monitoring for infection, which can lead to severe complications if not addressed promptly.

A. Place three pillows between the legs, one distal and three proximal. B. Side-lying position is permitted with a pillow between the legs. C. Sitting in a bedside chair is permitted if the legs are elevated. D. A triangular pillow is used between the legs to avoid adduction.

Correct Answer is D

Explanation

A. Place three pillows between the legs, one distal and three proximal: This is incorrect and excessive. Using three pillows in this manner can lead to improper leg positioning and discomfort.
B. Side-lying position is permitted with a pillow between the legs: While side-lying is allowed, the pillow is to prevent adduction of the legs, not just any pillow placement. It must specifically keep the hips aligned.
C. Sitting in a bedside chair is permitted if the legs are elevated: While sitting is often encouraged, elevating the legs too high can risk hip dislocation or improper alignment. The patient should sit in a way that maintains proper hip angles and alignment.
D. A triangular pillow is used between the legs to avoid adduction: A triangular or abduction pillow helps keep the legs in an appropriate position, preventing the legs from crossing and reducing the risk of hip dislocation post-surgery.

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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?

Nursing Test Bank

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