A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?

Change the client's position every 2 hr.

Place the client's right hand in a supination position.

Maintain NPO status for the client.

Perform range-of-motion exercises to the client's extremities.

Answer and Explanation

The Correct Answer is C

A. Change the client's position every 2 hr: Repositioning helps prevent skin breakdown and promotes circulation, which is important for stroke clients. However, it does not address the most immediate risk associated with right-sided weakness and facial drooping.

B. Place the client's right hand in a supination position: Proper positioning of the affected extremities prevents contractures and maintains joint alignment. While necessary for long-term care, it is not the highest priority in the immediate post-stroke period.

C. Maintain NPO status for the client: Right-sided weakness and facial drooping indicate potential dysphagia, placing the client at high risk for aspiration. Maintaining NPO status until a swallowing assessment is completed is the priority to prevent aspiration pneumonia, which is a life-threatening complication.

D. Perform range-of-motion exercises to the client's extremities: Range-of-motion exercises prevent contractures and maintain mobility. While important, this intervention is secondary to ensuring the client’s airway safety and preventing aspiration.

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Correct Answer is ["A","B","C","E"]

Explanation

A. The client takes 2 short naps during the day: The ability to rest indicates decreased hyperactivity and improved regulation of sleep-wake cycles, reflecting early stabilization of manic symptoms.

B. The client engages in quiet activities in their room: Participation in calm, structured activities demonstrates reduced agitation and impulsivity, suggesting improvement in mood stability and ability to focus.

C. The client slept 5 hr the previous night: Improved sleep duration is a positive sign, as insomnia and decreased need for sleep are hallmark symptoms of mania. Achieving rest indicates partial symptom resolution.

D. The client appears to listen to unseen others: Continued auditory hallucinations indicate persistent psychotic features and do not represent improvement. These symptoms require ongoing monitoring and treatment.

E. The client consumes 8 oz of high-calorie fluids each hour: Adequate fluid and calorie intake reflects improved self-care and nutrition, which are often compromised during acute manic episodes. This is a positive indicator of functional recovery.

A. Withdraw dose of regular insulin. B. Inject air into the vial of regular insulin. C. Inject air into the vial of NPH insulin. D. Withdraw dose of NPH insulin.

Correct Answer is C

Explanation

A. Withdraw dose of regular insulin: Withdrawing the regular insulin dose is performed after the air has been injected into both vials and the NPH insulin has been drawn up if using the “clear before cloudy” technique. Doing this first would risk disrupting the proper sequence and potentially contaminating the insulin.

B. Inject air into the vial of regular insulin: Air must be injected into the regular insulin vial before withdrawing the medication, but this step is performed after first injecting air into the NPH vial according to the standard procedure for mixing insulins. Starting with the regular insulin vial would not follow the recommended order.

C. Inject air into the vial of NPH insulin: Injecting air into the NPH insulin vial first is the initial step when preparing a mixed insulin dose. This step equalizes pressure inside the vial, allowing for easier withdrawal later, and follows the correct sequence of “air into cloudy first, then clear,” which prevents contamination of the regular insulin.

D. Withdraw dose of NPH insulin: Withdrawing NPH insulin is done after the regular insulin has been drawn into the syringe to maintain the correct “clear before cloudy” technique. Doing this first could result in accidental mixing or contamination of the regular insulin.

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A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is preparing to mix a dose of NPH insulin and regular insulin into a single syringe. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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