Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?
Apply an eye patch to the right eye.
Teach the patient that the left visual deficit will resolve.
Approach the patient from the right side.
Place needed objects on the patient's left side.
The Correct Answer is D
A. Apply an eye patch to the right eye: Applying an eye patch to the right eye would further limit the patient's visual field, exacerbating the homonymous hemianopsia. This intervention is not appropriate for managing hemianopsia.
B. Teach the patient that the left visual deficit will resolve: Homonymous hemianopsia typically results from damage to the visual pathway in the brain and may not resolve completely. While visual rehabilitation techniques may help improve compensatory strategies, it is important to acknowledge and address the permanent nature of the deficit.
C. Approach the patient from the right side: Approaching the patient from the right side may startle them and increase the risk of falls or accidents due to the inability to perceive objects on their left side. The nurse should approach the patient from the unaffected side (the left side) to minimize the risk of injury.
D. Place needed objects on the patient's left side: Placing needed objects on the patient's left side helps compensate for the visual deficit by ensuring that essential items are within the patient's field of vision. This intervention promotes independence and safety for the patient with homonymous hemianopsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "An MRI scan is not distorted by movement, so you do not have to lie still." This statement is incorrect. Movement during an MRI scan can distort images and affect the quality of the diagnostic information obtained. Patients are typically instructed to lie as still as possible during the procedure.
B. "The MRI contrast dye contains iodine and can cause your skin to itch." This statement is incorrect. MRI contrast agents do not contain iodine and are not associated with itching.
However, some patients may experience allergic reactions to MRI contrast agents, but this is not related to iodine.
C. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." This statement is correct. MRI scanners produce loud noises during imaging, which can be bothersome to some patients. Patients are often provided with earplugs or headphones to help reduce the noise and make the experience more comfortable.
D. "An MRI scan is a short procedure and should take no longer than 30 minutes." This statement is incorrect. The duration of an MRI scan can vary depending on the type of imaging being performed and the specific protocol used. Some MRI scans may take longer than 30 minutes to complete.
Correct Answer is C
Explanation
A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.
B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.
C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.
D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.
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