The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

Support the right arm with a sling or pillow to prevent shoulder dislocation.

Anticipate the client will exhibit some degree of expressive or receptive aphasia.

Place the wheelchair on the client’s left side when transferring him into a wheelchair.

Provide close supervision because of the client’s impulsiveness and poor judgment.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale

Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.

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Correct Answer is C

Explanation

Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale

While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.

A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

Correct Answer is A

Explanation

Choice A rationale
Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.

Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.

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The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Correct Answer is C

Explanation

The nurse is conducting an assessment on a patient suspected of having a stroke. Which assessment finding is most indicative of a stroke?

Correct Answer is A

Explanation

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