The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?
Instruct the UAP to protect the client's left side when transferring to a chair.
Demonstrate to the UAP how to approach the client from the client's left side.
Carefully observe the interaction between the client and family members.
Ask the UAP to leave the room and assess the client's body for bruising.
The Correct Answer is B
A. Protecting the client's left side during transfers is not directly related to addressing neglect syndrome. Clients with right hemisphere strokes may neglect the left side, but the UAP should be guided to approach from the left to help manage the neglect.
B. Demonstrating to the UAP how to approach the client from the left side helps manage the effects of neglect syndrome. Clients with right hemisphere strokes may not be aware of or may ignore the left side, so approaching from this side can improve the client’s awareness and safety.
C. Observing interactions between the client and family members might provide insights into the client’s condition but is not a direct intervention for managing neglect syndrome. The focus should be on practical strategies to help the client with neglect.
D. Asking the UAP to leave the room and assessing the client for bruising does not address the immediate needs of managing neglect syndrome. The priority is to ensure the client is safely engaged and managed, rather than performing a solitary assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maternal hypotension is a significant adverse effect of epidural anesthesia that can lead to decreased uterine blood flow and fetal distress. Monitoring for hypotension is critical to ensure both maternal and fetal well-being.
B. While a vaginal hematoma is a potential complication, it is less immediately associated with the administration of epidural anesthesia compared to hypotension.
C. A continuous headache could indicate post-dural puncture but is less common and not the primary immediate concern compared to hypotension following an epidural.
D. Urinary retention can occur with epidural anesthesia, but maternal hypotension is a more urgent and significant immediate concern.
Correct Answer is C
Explanation
A. Moisture is important for skin assessments but does not directly affect the accuracy of a temporal artery temperature measurement.
B. Elasticity is part of skin turgor assessments and does not impact the accuracy of the temperature reading from a temporal artery scanner.
C. Assessing skin color is crucial because variations in skin color can affect the accuracy of the temporal artery temperature measurement. For accurate results, the skin should be clean and free of color alterations.
D. Checking the temperature of the skin is the outcome of the measurement process rather than a preliminary assessment for a temporal artery scanner.
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