While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Teach the client to rotate the meal plate to visualize all the food on the plate.

Instruct the client to lift the left extremities with the right hand when transferring.

Implement precautions when the client is judging distances during transfers.

Encourage the client to touch, wash, look at, and dress the affected side first.

Answer and Explanation

The Correct Answer is C

A. Teach the client to rotate the meal plate to visualize all the food on the plate: While this intervention may be helpful for other reasons, it does not directly address the client’s difficulty walking in a straight line.

B. Instruct the client to lift the left extremities with the right hand when transferring: This intervention helps with weight-bearing and balance during transfers. It compensates for the left hemiplegia and promotes stability.

C. Implement precautions when the client is judging distances during transfers: This is crucial. Clients with hemiplegia may have impaired spatial awareness and difficulty judging distances. Strategies like using a gait belt, providing cues, or ensuring a clear path can help prevent falls. Implementing precautions during transfers helps prevent falls.

D. Encourage the client to touch, wash, look at, and dress the affected side first: While this approach promotes independence, it does not directly address the client’s gait instability.

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Correct Answer is D

Explanation

A. Notify the healthcare provider. While notifying the healthcare provider is important if the issue persists, the nurse should first attempt to confirm the absence of pulses using other methods to ensure it is not a technical error or due to poor technique.

B. Apply warm blankets to both feet. Warming the feet might help if the pulses are weak due to vasoconstriction from cold, but this is not the most immediate or effective action to determine the presence of pulses.

C. Palpate pulse points with legs dependent. Having the legs in a dependent position might increase blood flow to the lower extremities, potentially making pulses easier to palpate. However, this is not as reliable as using more advanced technology.

D. Use a doppler ultrasonic stethoscope. Using a Doppler device is the best next step if pulses are not palpable. Dopplers can detect blood flow that is not palpable, providing more accurate assessment of circulation in the extremities before notifying the healthcare provider.

A. Deep, continuous pain in the calf muscles. B. Painful symptoms alleviated by warmth. C. Cool, pale skin below the knees. D. Decreased pain when legs are elevated.

Correct Answer is D

Explanation

A. Deep, continuous pain in the calf muscles. This symptom is more indicative of deep vein thrombosis (DVT) rather than venous insufficiency.

B. Painful symptoms alleviated by warmth. This symptom is not typically associated with venous insufficiency; it may be seen in conditions like arthritis.

C. Cool, pale skin below the knees. This finding is more suggestive of arterial insufficiency rather than venous insufficiency.

D. Decreased pain when legs are elevated. Venous insufficiency is characterized by impaired blood flow in the veins, leading to symptoms such as leg aching, tiredness, swelling, and skin changes like leathery appearance. Elevating the legs can help alleviate symptoms of venous insufficiency by reducing venous pressure and improving blood flow back to the heart. Therefore, a subjective finding indicating decreased pain when the legs are elevated suggests venous insufficiency.

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While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Correct Answer is D

Explanation

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Correct Answer is D

Explanation

A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

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When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

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