The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain with opposite side affected extremities. The nurse notices that the patient does not easily reach items placed at the bedside. In which area does the nurse place items for easy access?
Left Side
Right Side
Directly in front
Where the patient wants
The Correct Answer is B
A. Placing items on the left side would not be appropriate for a patient with a right-sided weakness (hemiparesis) due to a left-sided ischemic stroke. This would make it harder for the patient to reach the items.
B. Placing items on the right side of the patient is the best option. Since the patient has weakness on the right side, they would have better access to items placed on the unaffected side (left side of the body).
C. Placing items directly in front of the patient could be helpful, but it depends on the severity of the stroke and the patient's ability to move and reach forward. It may not be as effective if the patient has limited mobility.
D. Placing items where the patient wants is a good practice, but the nurse should ensure the placement is practical for the patient's abilities. It is more important to place items on the right side to optimize access.
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Related Questions
Correct Answer is B
Explanation
A. Increased LOC (level of consciousness) and increased range of motion are not typical symptoms of increased intracranial pressure (ICP). In fact, ICP usually leads to a decreased level of consciousness, not an increase.
B. Restlessness, irritability, and decreased LOC are early signs of increased intracranial pressure. As pressure inside the skull rises, the brain becomes less able to function normally, leading to changes in behavior and cognition, such as restlessness and irritability, followed by a decrease in consciousness.
C. Pain in the calf and neck is not a typical symptom of ICP. While neck pain may occur with certain neurological conditions, it is not a hallmark of increased intracranial pressure.
D. Fever and chills are not initial symptoms of ICP. These symptoms are more indicative of infection, such as meningitis, rather than increased intracranial pressure.
Correct Answer is A
Explanation
A. Huntington disease is an autosomal dominant genetic disorder, meaning that if one parent has the gene, each child has a 50% chance of inheriting it. Therefore, all family members are at risk for the disease.
B. While genetic testing may be relevant for the patient’s children, it is not limited only to them. The patient and other family members are also at risk and may choose to be tested.
C. Huntington disease typically manifests between ages 30 and 50, and there is no age cutoff for determining risk. Early diagnosis may occur, but not being diagnosed by age 20 does not rule out the disease.
D. While genetic testing can confirm the presence of the gene, it is not the only way to determine risk. Family history and clinical symptoms are also key factors in understanding the risk for Huntington disease.
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