The nurse is assigned to care for a client with complete right-sided hemiparesis [weakness] from a stroke (brain attack).
admitting diagnosis
cerebrovascular attack
Right-sided hemiparesis
Which characteristics are associated with this condition? Select 2 that apply.
The client has complete bilateral paralysis of the arms and legs.
The client has lost the ability to move the right arm but is able to walk independently.
The client has lost the ability to move the right arm but is able to walk independently.
The client has weakness on the right side of the face and tongue.
The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.
The client has weakness on the right side of the body.
Correct Answer : D,F
A. This statement indicates complete paralysis of both sides, which does not apply to hemiparesis, where one side is affected.
B. While this could describe some patients, it does not accurately represent "complete" right-sided hemiparesis.
C. This option is a repeat and also does not accurately reflect complete right-sided hemiparesis.
D. Weakness on the right side of the face and tongue is consistent with right-sided hemiparesis, as the stroke may affect motor control in those areas.
E. This describes a client who is less severely affected and may not apply to someone with complete right-sided hemiparesis.
F. Weakness on the right side of the body is a direct characteristic of right-sided hemiparesis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Response to verbal stimuli does not directly assess the function of cranial nerves III, IV, and VI.
B. Affect, feelings, or emotions are related to the assessment of other neurological functions and do not evaluate the ocular cranial nerves specifically.
C. Eye movements are the primary function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye movement and provide essential information about their function.
D. Insight, judgment, and planning relate more to cognitive function and do not directly assess the function of the cranial nerves in question.
Correct Answer is ["A","C","D"]
Explanation
A. PICC line insertion site: The client reports pain, redness, and edema at the PICC line insertion site, which are signs of a possible infection. This finding requires immediate follow-up to prevent complications like bloodstream infection or sepsis.
B. Breath sounds: The client’s breath sounds are clear and unchanged from Day 1, so this finding does not require immediate follow-up.
C. Temperature: The client's temperature has risen to 39 °C (102.2 °F) from 37.2 °C (99 °F) on Day 1. Such a significant increase in temperature indicates a possible infection and needs prompt intervention.
D. Heart rate: The client’s heart rate has increased to 108/min from 66/min, suggesting tachycardia. This could be a response to infection, potentially linked to sepsis, and warrants immediate follow-up.
E. Albumin level: The albumin level has increased to within the normal range, which is a positive trend and does not require urgent intervention.
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