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 B

Explanation

A.Crackles: Crackles, also known as rales, are abnormal lung sounds that can indicate conditions such as pneumonia, pulmonary edema, or interstitial lung disease. They are often described as fine or coarse, and they may be heard during inspiration, expiration, or both. Crackles are typically heard over areas of fluid-filled alveoli or small airways.

B. Vesicular. These sounds are typically heard over most of the lung fields and are associated with normal airflow through smaller airways.

C. Bronchial: Bronchial breath sounds are typically heard over the trachea and mainstem bronchi. These sounds are louder and higher in pitch compared to vesicular sounds, with a shorter inspiratory phase and a longer expiratory phase. Hearing bronchial sounds over peripheral lung fields would suggest consolidation or compression of lung tissue, such as in pneumonia or atelectasis.

D. Wheezes: Wheezes are high-pitched, musical sounds heard primarily during expiration. They are typically associated with narrowed airways, such as in asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. Wheezes may be heard over the lung fields if there is widespread airway obstruction or bronchoconstriction.

A. Bulges. B. Nontender. C. Tenderness. D. Thrill.

Correct Answer is B

Explanation

A. Bulges. Bulges might indicate abnormalities such as masses or hernias and are not considered normal findings.

B. Nontender. This is the expected finding in a healthy individual without thoracic abnormalities.

C. Tenderness. Tenderness might indicate inflammation, injury, or other underlying conditions and should be further assessed.

D. Thrill. Thrill refers to a vibrating sensation caused by turbulent blood flow and is not typically assessed during thoracic palpation.

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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

The nurse auscultates a client's breath sounds as seen in the picture. Which type of normal sounds should the nurse hear over these lung fields?

Correct Answer is B

Explanation

The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

Correct Answer is B

Explanation

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