The nurse is assigned to care for a client with complete right-sided hemiparesis

10 Questions  |  By Santepro | Last updated: Mar 22, 2022 | Total Attempts: 13585

The nurse is assigned to care for a client with complete right-sided hemiparesis
The nurse is assigned to care for a client with complete right-sided hemiparesis
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The nurse is assigned to care for a client with complete right-sided hemiparesis

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  • 1. 

    A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:

    • A. 

      Is clear and tests negative for glucose

    • B. 

      Is grossly bloody in appearance and has a pH of 6

    • C. 

      Clumps together on the dressing and has a pH of 7

    • D. 

      Separates into concentric rings and test positive of glucose

  • 2. 

    A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

    • A. 

      Strict adherence to a bowel retraining program

    • B. 

      Keeping the linen wrinkle-free under the client

    • C. 

      Preventing unnecessary pressure on the lower limbs

    • D. 

      Limiting bladder catheterization to once every 12 hours

  • 3. 

    The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following actions by the nurse would be contraindicated?

    • A. 

      Loosening restrictive clothing

    • B. 

      Restraining the client’s limbs

    • C. 

      Removing the pillow and raising padded side rails

    • D. 

      Positioning the client to side. if possible. with the head flexed forward

  • 4. 

    The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:

    • A. 

      The client has complete bilateral paralysis of the arms and legs.

    • B. 

      The client has weakness on the right side of the body. including the face and tongue.

    • C. 

      The client has lost the ability to move the right arm but can walk independently.

    • D. 

      The client has lost the ability to move the right arm but can walk independently.

  • 5. 

    The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated. the nurse avoids doing which of the following?

    • A. 

      Giving the client thin liquids

    • B. 

      Thickening liquids to the consistency of oatmeal

    • C. 

      Placing food on the unaffected side of the mouth

    • D. 

      Allowing plenty of time for chewing and swallowing

  • 6. 

    The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:

    • A. 

      Gets angry with family if they interrupt a task

    • B. 

      Experiences bouts of depression and irritability

    • C. 

      Has difficulty with using modified feeding utensils

    • D. 

      Consistently uses adaptive equipment in dressing self

  • 7. 

    Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client?

    • A. 

      Speaking to the client at a slower rate

    • B. 

      Allowing plenty of time for the client to respond

    • C. 

      Completing the sentences that the client cannot finish

    • D. 

      Looking directly at the client during attempts at speech

  • 8. 

    A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:

    • A. 

      Getting too little exercise

    • B. 

      Taking excess medication

    • C. 

      Omitting doses of medication

    • D. 

      Increasing intake of fatty foods

  • 9. 

    The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:

    • A. 

      Eating large. well-balanced meals

    • B. 

      Doing muscle-strengthening exercises

    • C. 

      Doing all chores early in the day while less fatigued

    • D. 

      Taking medications on time to maintain therapeutic blood levels

  • 10. 

    A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is:

    • A. 

      Unknown. but possibly includes ischemia. viral infection. or an autoimmune problem

    • B. 

      Unknown. but possibly includes long-term tissue malnutrition and cellular hypoxia

    • C. 

      Primary genetic in origin. triggered by exposure to meningitis

    • D. 

      Primarily genetic in origin. triggered by exposure to neurotoxins

The nurse is assigned to care for a client with complete right-sided hemiparesis
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