An adult client is admitted to the nursing unit with a medical diagnosis of Acute Stroke. The client does not respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response?

Apply pressure to the temporomandibular joint (TM)

Squeeze the trapezius muscle

Press hard on the client's sternum

Gently shake the client's shoulders

Answer and Explanation

The Correct Answer is C

A.   While pressure on the TM joint could stimulate a response, it is not the most appropriate method for provocation of a response in an unconscious or semiconscious client.
B.   This action can be used to assess for painful stimuli, but pressing on the sternum is a more effective method for provoking a response in non-responding clients.
C.   Applying firm pressure to the sternum, or sternal rub, is an effective technique to stimulate a response from clients who are non-responsive to verbal stimuli.
D.   While shaking might be used for awakening a client, it is not as reliable or effective as a sternal rub when assessing neurological response in acute stroke patients.

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Correct Answer is A

Explanation

A. A positive Romberg test occurs when a person loses balance or sways when standing with their eyes closed, indicating a problem with proprioception or balance.
B. Ataxia refers to a lack of coordination or motor control, but the Romberg sign specifically tests balance and proprioception, which is different from ataxia.
C. Lack of coordination may be part of ataxia or other neurological issues, but the Romberg sign specifically refers to balance issues when eyes are closed.
D. The Homans sign is used to test for deep vein thrombosis (DVT) and is not relevant to the test for balance and proprioception described in the scenario.

A. Frontal B. Occipital C. Temporal D. Parietal

Correct Answer is A

Explanation

A. The frontal lobe is responsible for a variety of functions, including personality, behavior, judgment, and emotional regulation. It also plays a key role in problem-solving and decision-making. Changes in these areas, such as the emotional instability (crying and anger) described in the question, are often linked to frontal lobe dysfunction.
B. The occipital lobe is primarily responsible for visual processing. Damage or issues in the occipital lobe typically affect vision, such as causing blindness or visual disturbances, rather than emotional or behavioral changes like those described in the scenario.
C. The temporal lobe is involved in processing auditory information, memory, and language. While damage to the temporal lobe can affect memory or speech, it is not primarily responsible for the emotional and personality changes described in the scenario. Temporal lobe damage is more commonly associated with memory loss or issues with speech.
D. The parietal lobe is responsible for sensory information and spatial awareness. While damage here can lead to problems with spatial orientation or sensation, it is not directly responsible for emotional regulation or changes in personality and behavior like those described in the question.

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An adult client is admitted to the nursing unit with a medical diagnosis of Acute Stroke. The client does not respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response?

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Naxlex Comprehensive Predictor Exams

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

Correct Answer is A

Explanation

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the……..lobe.

Correct Answer is A

Explanation

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