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

Explanation

A. Attempt to determine what the client was looking for is the best response. In Alzheimer's disease, clients may exhibit wandering behavior and confusion, often seeking something familiar or trying to meet an unmet need. Understanding what the client was looking for can help address their needs and prevent further agitation.

B. Reprimanding the client for invading the other client's privacy is not appropriate. Clients with Alzheimer's disease may not be aware of the concept of privacy or the impact of their actions. Reprimanding can cause distress and confusion.

C. Explaining the client's Alzheimer's diagnosis to the frightened client may help provide understanding, but it does not address the immediate concern of calming the frightened client. The focus should be on managing the behavior in the moment.

D. Asking the client to apologize for his behavior is not appropriate, as the client may not have the cognitive ability to understand or remember the need to apologize. This could cause frustration and confusion.

A. 700 B. 660 C. 900 D. 960

Correct Answer is B

Explanation

A. 700: This is incorrect, check the calculation in choice D rationale
B. 660: This is incorrect, check the calculation in choice D rationale

C. 900: This is incorrect, check the calculation in choice D rationale
D. To calculate the total intake, we need to convert all fluid measurements to milliliters (mL) and then add them together:

- Coffee: 240 mL

- Milk: 60 mL

- Apple juice: 120 mL

- Broth: 8 oz = 240 mL (1 oz = 30 mL)

- Water: 10 oz = 300 mL (1 oz = 30 mL)

Now, add them together:

240 mL (coffee) + 60 mL (milk) + 120 mL (apple juice) + 240 mL (broth) + 300 mL (water) = 960 mL.

Thus, the total intake is 960 mL, which corresponds to D.

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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

A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

For the 0700 to 1500 shift, the patient drinks 240 mL of coffee, 60 mL of milk, and 120 mL of apple juice at breakfast. For lunch, the patient takes 8 oz of broth and drinks 10 oz of water for the shift. What is the total intake for the 0700 to 1500 shift?

Correct Answer is B

Explanation

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