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

Answer and Explanation

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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Correct Answer is ["A","B","E"]

Explanation

A. Vasoconstrictors (Imitrex), such as sumatriptan, are commonly used to treat the headache stage of a migraine by constricting blood vessels, which helps alleviate the pain.

B. A dark, quiet environment is beneficial for migraine sufferers as bright lights and loud noises can exacerbate symptoms. Resting in a calm environment can help reduce discomfort.

C. While teaching relaxation is helpful for migraine prevention, it may not be effective in the acute phase of the headache. Relaxation techniques are more useful in managing triggers and reducing frequency.

D. Exercise is generally not recommended during the headache stage of a migraine, as it can worsen the pain. Light activity may help during the prodromal phase, but not during the headache itself.

E. Analgesics (NSAIDs) such as ibuprofen or naproxen are often used to relieve the pain during the headache stage of a migraine. They can help reduce inflammation and discomfort.

F. Teaching stress reduction is beneficial for preventing migraines but is not typically helpful during the headache stage itself. Stress management is more useful in the long term.

A. ECG tracing shows irregularly irregular heart rate without P waves. B. Slurred speech C. aPTT result of 70 seconds D. Urine output is cloudy and odorous

Correct Answer is B

Explanation

A. The ECG finding of an irregularly irregular heart rate without P waves is characteristic of atrial fibrillation, which is expected in this client. This finding is not the priority in this situation.

B. Slurred speech is a potential sign of a stroke, which is a serious complication of atrial fibrillation due to the increased risk of thromboembolic events (e.g., stroke). This is the priority finding because it requires immediate intervention to assess and manage a possible stroke.

C. An aPTT of 70 seconds is slightly elevated, but it is within the therapeutic range for heparin therapy (usually 1.5 to 2.5 times the normal value). It does not warrant immediate action.

D. Cloudy and odorous urine could indicate a urinary tract infection or other issue, but it is not immediately life-threatening compared to the potential for a stroke in this client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a client is in the headache stage of a migraine headache, which of the following may help the person cope with this stage? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

Correct Answer is B

Explanation

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