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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.
Choice B rationale
Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.
Choice C rationale
Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.
Choice D rationale
Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.
Correct Answer is ["56"]
Explanation
Step 1 is (250 mL ÷ 90 min) × 20 gtt/mL.
Step 2 is (2.777 mL/min × 20 gtt/mL).
Step 3 is 55.55 gtts/min. The final calculated answer is 56 gtts/min.
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