A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

The client is consuming 25% of their meals.

The client coughs frequently while eating.

The client's blood pressure is 142/94 mm Hg.

The client leans to the left side while sitting.

Answer and Explanation

The Correct Answer is B

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

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Correct Answer is B

Explanation

A. "I will move your joints to the point of mild pain":

This statement is incorrect. Passive range-of-motion exercises should not cause pain. The goal is to move the joints within their natural range of motion without causing discomfort or harm to the client. If pain occurs, the nurse should stop the movement and assess for any underlying issues.

B. "I will repeat these movements 3 to 5 times":

This is the correct statement. Passive range-of-motion exercises involve moving the client's joints through their range of motion without the client actively participating. Repeating the movements 3 to 5 times helps prevent joint stiffness and maintain flexibility without causing excessive strain or fatigue.

C. "These movements will be performed once per day":

This statement is less optimal. While performing passive range-of-motion exercises once a day may be beneficial, incorporating them into the client's routine more frequently, such as several times a day, can provide additional benefits in preventing joint contractures and maintaining joint function.

D. "I will move your joints quickly":

This statement is incorrect. Passive range-of-motion exercises should be performed slowly and gently. Moving the joints too quickly may cause discomfort or injury. The emphasis is on smooth, controlled movements to promote joint flexibility without causing harm.

A. Direct a fire extinguisher at the fire. B. Place wet towels along the base of the door. C. Turn off any electrical equipment. D. Activate the facility's fire alarm.

Correct Answer is D

Explanation

A. Direct a fire extinguisher at the fire:

While using a fire extinguisher is an essential action in controlling a small fire, it should come after the fire alarm has been activated. Alerting others to the fire and initiating the emergency response system take precedence to ensure a coordinated and safe response.

B. Place wet towels along the base of the door:

Placing wet towels along the base of the door is a method to help prevent smoke from entering the room. However, in this situation, after ensuring the client's safety, the nurse should focus on activating the facility's fire alarm to alert others and initiate the emergency response.

C. Turn off any electrical equipment:

While turning off electrical equipment is a generally sound practice in fire safety, it is not the immediate next action after moving the client to safety. Activating the fire alarm takes precedence as it initiates a coordinated response and alerts others to the emergency.

D. Activate the facility's fire alarm:

This is the correct action. Activating the fire alarm is a critical step in alerting the entire facility to the presence of a fire. It ensures that emergency response teams are notified promptly, and appropriate measures can be taken to address the fire, including evacuating other occupants and summoning professional firefighting assistance.

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A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

Correct Answer is D

Explanation

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