A nurse is assessing a client experiencing motor loss as the result of a left-sided stroke.
Which clinical manifestations would the nurse document?

Hemiparesis of the right side of the body and ataxia.

Spasticity of the client's left arm and apraxia.

Impulsive behavior and hostility toward family.

Homonymous hemianopia and diplopia.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Hemiparesis on the right side and ataxia are common manifestations of left-sided stroke, where the motor cortex affecting the contralateral side is impaired, leading to muscle weakness and coordination loss.

Choice B rationale

Spasticity of the left arm suggests motor impairment on the ipsilateral side, which is inconsistent with the nature of left-sided strokes affecting the contralateral side. Apraxia lacks relation to motor loss here.

Choice C rationale

Impulsive behavior and hostility are more indicative of frontal lobe involvement, not motor loss secondary to left-sided strokes. These behaviors do not represent motor manifestations.

Choice D rationale

Visual defects like homonymous hemianopia and diplopia may occur in stroke but are not direct indicators of motor loss. They relate to occipital lobe or optic pathway damage.

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Correct Answer is ["D","E"]

Explanation

Choice A rationale

Weekly appointments to change the catheter are unnecessary unless specifically indicated. Most urinary catheters are changed monthly or as needed based on physician's discretion or complications.

Choice B rationale

Sexual intimacy is possible with an indwelling urinary catheter if handled properly. Providing education on safe practices promotes normalcy and quality of life for the patient.

Choice C rationale

Wearing underwear is recommended to protect the catheter and minimize risk of contamination or accidental dislodgement. This information supports proper hygiene and comfort.

Choice D rationale

Regular emptying of the leg bag every 4 hours or more frequently prevents overfilling, which could lead to backflow and increased risk of urinary tract infections.

Choice E rationale

Foul-smelling, cloudy urine can indicate infection such as a urinary tract infection. Prompt reporting ensures early treatment and prevention of complications.

Correct Answer is ["2525"]

Explanation

Step 1 is calculate intake from lactated Ringer’s: 150 mL/hr × 9 hrs = 1350 mL.

Step 2 is calculate cefazolin intake: 100 mL × 1 dose = 100 mL.

Step 3 is calculate intake from two units of packed RBCs: 275 mL + 250 mL = 525 mL.

Step 4 is calculate intake from two IV boluses: 250 mL × 2 = 500 mL.

Step 5 is calculate intake from ranitidine infusion: 50 mL × 1 dose = 50 mL.

Step 6 is calculate total intake: 1350 mL + 100 mL + 525 mL + 500 mL + 50 mL = 2525 mL. Final calculated intake is 2525 mL.

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A nurse is assessing a client experiencing motor loss as the result of a left-sided stroke.Which clinical manifestations would the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter.What would the nurse emphasize about catheter care? (Select All that Apply.)

Correct Answer is ["D","E"]

Explanation

Correct Answer is ["2525"]

Explanation

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A nurse is assessing a client experiencing motor loss as the result of a left-sided stroke.
Which clinical manifestations would the nurse document?