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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The sympathetic nervous system is responsible for the "fight or flight" response. This response includes tachycardia (increased heart rate) and dilated pupils (mydriasis), both of which are common physiological changes during sympathetic activation.
B. Pupil constriction and bronchoconstriction are associated with the parasympathetic nervous system, which is responsible for the "rest and digest" functions.
C. Increased peristalsis and abdominal cramping are also associated with the parasympathetic nervous system, as it promotes digestion and relaxation of the body.
D. Hypoglycemia and headache are not direct indicators of sympathetic activation. Hypoglycemia can occur for various reasons, and headaches can be caused by multiple factors, but they are not specific signs of sympathetic nervous system activation.
Correct Answer is D
Explanation
A. A positive Romberg sign (difficulty maintaining balance with eyes closed) can indicate a neurological issue, but it is not directly associated with a migraine.
B. A subnormal temperature (low body temperature) is not typically associated with migraines and may indicate another issue, but it is not as concerning as other findings.
C. An ill college roommate might suggest a viral illness, but it is not a direct concern for the student’s migraine. Migraines are not contagious, and other signs of illness would be more concerning.
D. Positive Brudzinski sign, which involves involuntary flexion of the hips and knees when the neck is flexed, is indicative of meningeal irritation, a sign of meningitis. This is a medical emergency and much more concerning than the symptoms of a migraine. The student should be further assessed for signs of meningitis, which requires urgent treatment.
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