A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Encourage the use of the wide grip utensils.
Remind the client to look for food on the left side of the tray.
Encourage the client to use his right hand when feeding himself.
Provide a nonskid mat to alleviate plate movement.
The Correct Answer is B
A. Wide grip utensils may help with grasp but do not address visual field deficits.
B. Homonymous hemianopsia involves loss of vision in one half of the visual field; reminding the client to look to the left side of the tray helps them find food in their impaired visual field.
C. Using the right hand is not specifically beneficial for visual field deficits and may not address the issue of homonymous hemianopsia.
D. A nonskid mat helps prevent plate movement but does not address the visual field deficit caused by homonymous hemianopsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Condition:
A. Transfusion-associated circulatory overload (TACO)
Rationale: The client’s symptoms—dyspnea, restlessness, crackles in the lungs, jugular vein distension, and elevated blood pressure—are consistent with TACO, a condition resulting from excessive fluid volume during a blood transfusion.
Actions to Take:
C. Administer furosemide
Rationale: Furosemide is a diuretic that helps reduce fluid overload, which is a key issue in TACO.
B. Administer diphenhydramine
Rationale: Although not the primary treatment for TACO, diphenhydramine can help manage symptoms if there is a mild allergic reaction contributing to the situation.
Parameters to Monitor:
A. Intake and output
Rationale: Monitoring intake and output helps assess fluid balance and effectiveness of treatment for TACO.
D. Weight
Rationale: Weight monitoring helps assess fluid overload and effectiveness of diuretic therapy
Correct Answer is B
Explanation
A. Learning to control impulsive behavior is more relevant for a right hemispheric CVA, which affects impulse control and judgment.
B. Establishing the ability to communicate effectively is crucial for a left hemispheric CVA, which often affects language and speech functions.
C. Compensating for loss of depth perception is related to right hemispheric CVA, which affects spatial awareness and perception.
D. Improving left-side motor function is important but secondary to addressing communication issues in a left hemispheric CVA where language deficits are a priority.
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