A client with a right hemisphere stroke is eating lunch.
The nurse notes the client is only eating food from the right side of the tray and is unaware of food remaining on the left side. What is the nurse's priority action?
Document the client's behavior as expected.
Remind the client to scan the entire tray before eating.
Assist the client with feeding from the unaffected side.
Remove the tray and notify the provider.
The Correct Answer is B
The scenario requires application of neurobiological principles regarding right-sided cerebrovascular accidents. Knowledge of hemispatial neglect and safety interventions is essential to address visual field deficits. Prioritization focuses on promoting compensatory behaviors to ensure adequate nutritional intake and safety during meals.
Choice A rationale
Stroke damage to the right parietal lobe often results in unilateral neglect. While clinically expected, documentation is a secondary action that does not address the immediate physiological need for nutrition or safety while the client is currently eating.
Choice B rationale
Visual scanning techniques utilize conscious cognitive effort to bypass damaged neural pathways in the right hemisphere. Training the client to look left compensates for hemispatial neglect, ensuring they receive adequate nutrients and maintain awareness of their immediate environment.
Choice C rationale
Feeding assistance fosters dependence and does not encourage neuroplasticity or self-care. The nursing goal is to promote independence through rehabilitation strategies, such as environmental scanning, rather than performing tasks that the client can achieve with verbal cues.
Choice D rationale
Removing the food tray prevents the client from completing their meal, which could lead to nutritional deficits. Notifying the provider is unnecessary for an expected stroke symptom when nursing interventions like scanning can effectively manage the issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Step 1 is 1 mg ÷ (0.1 mg ÷ 1 mL).
Step 2 is 1 mg ÷ 0.1 mg/mL = 10 mL. Final answer is 10 mL..
Correct Answer is B
Explanation
Acute pancreatitis involves the autodigestion of the pancreas by activated enzymes. Knowledge of systemic inflammatory response and gastric acid management is necessary to understand the rationale for bowel rest and the prevention of secondary complications like stress ulcers.
Choice A rationale
Early ambulation is generally encouraged but not a priority during the acute, painful phase of pancreatitis. The client often requires bed rest to decrease metabolic demands and minimize the stimulation of pancreatic enzyme secretion and activity.
Choice B rationale
Pantoprazole is a proton pump inhibitor used to decrease gastric acid secretion. In pancreatitis, reducing acid prevents it from entering the duodenum and stimulating the release of secretin, which would otherwise trigger further pancreatic enzyme production.
Choice C rationale
Pancrelipase consists of digestive enzymes meant for chronic pancreatitis or pancreatic insufficiency. In acute pancreatitis, giving enzymes orally would further stimulate the inflamed organ and worsen the condition; the client must remain nothing by mouth.
Choice D rationale
A low-residue diet is inappropriate for acute pancreatitis. The initial treatment must be strict bowel rest (NPO) to stop all stimulus to the pancreas, allowing the inflammation to subside before reintroducing any oral intake or nutrients..
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