A patient who is diagnosed with a stroke is requesting a glass of water. Which action is appropriate for the nurse to take?

Give the patient a glass of water.

Check the patient's dysphagia screen

Consult speech pathology.

Teach that stroke patients are nothing by mouth (NPO)

Answer and Explanation

The Correct Answer is B

A. Give the patient a glass of water.: Giving the patient water without assessing their swallowing ability can be dangerous due to the risk of aspiration.
B. Check the patient's dysphagia screen.: Assessing for dysphagia is crucial because stroke patients often have impaired swallowing, which increases the risk of aspiration and choking.
C. Consult speech pathology.: Consulting a speech pathologist is important for a comprehensive swallowing assessment, but it is not the immediate action when a patient requests water.
D. Teach that stroke patients are nothing by mouth (NPO).: Not all stroke patients are NPO. This decision is based on the patient's ability to swallow safely, determined by a dysphagia screen.

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Correct Answer is B

Explanation

A. Impaired Physical Mobility: This is not directly related to hypertension management. While hypertension can affect physical activity, it is not the primary focus in the context of managing high blood pressure.
B. Readiness for Enhanced Health Literacy: This is the correct focus. Educating the patient about hypertension management, lifestyle modifications, and medication adherence is crucial in managing and controlling blood pressure.
C. Decreased Activity Tolerance: This could be a related issue but is not the primary focus. It addresses the impact of hypertension on physical capacity rather than managing the condition itself.
D. Ineffective Airway Clearance: This is unrelated to hypertension. It focuses on respiratory issues rather than blood pressure management.

A. Transient ischemic attack B. Basilar artery syndrome C. Left middle cerebral artery syndrome D. Right middle cerebral artery syndrome

Correct Answer is C

Explanation

A. Transient ischemic attack (TIA): A TIA might cause transient symptoms similar to a stroke, including weakness and dysphasia, but it would not explain why the symptoms are localized to the right side of the body. Additionally, TIA symptoms typically resolve within 24 hours.
B. Basilar artery syndrome: This type of stroke affects the brain stem, resulting in symptoms such as double vision, vertigo, and ataxia, rather than localized right-sided weakness and dysphasia.
C. Left middle cerebral artery syndrome: The left middle cerebral artery (MCA) supplies blood to the left hemisphere of the brain, including areas that control language and motor function on the right side of the body. Thus, an infarct in this area often leads to right-sided weakness and dysphasia, making it the most likely suspect.
D. Right middle cerebral artery syndrome: This would typically result in left-sided weakness and possibly neglect, but not right-sided symptoms

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A patient who is diagnosed with a stroke is requesting a glass of water. Which action is appropriate for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse contributes to the plan of care for a patient with hypertension. Which of the following nursing diagnoses is the focus of care for the patient with hypertension?

Correct Answer is B

Explanation

The nurse is caring for a patient who presents to the emergency department with right-sided weakness and dysphasia. Which type of stroke would the nurse suspect?

Correct Answer is C

Explanation

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