A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

Encouraging the client to use a cane as needed for mobility

Encouraging the client to use their right hand for daily activities

Encouraging the client to consume a soft diet and thickened liquids

Encouraging the client to complete all activities of daily living (ADLs) independently

Answer and Explanation

The Correct Answer is A

A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.

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Correct Answer is A

Explanation

A. Clay-colored stools are indicative of a bile duct obstruction because bile is not reaching the intestines, leading to pale or clay-colored stools.
B. Tenderness in the left upper abdomen is more commonly associated with issues such as splenic or gastric problems rather than a bile duct obstruction.
C. Ecchymosis of the extremities is not typically associated with bile duct obstruction. It might indicate other issues such as bleeding disorders.
D. Straw-colored urine is not indicative of bile duct obstruction; typically, the urine would appear darker due to elevated bilirubin levels from bile duct obstruction.

A. Bradykinesia, hand tremors, and memory loss B. Ascending paralysis beginning in the lower extremities and dysphagia C. Areas of numbness, weakness in the legs, visual problems D. Choreiform movements and loss of facial expression

Correct Answer is C

Explanation

A. Bradykinesia, hand tremors, and memory loss are more characteristic of Parkinson's disease, not multiple sclerosis.
B. Ascending paralysis beginning in the lower extremities and dysphagia are typical of Guillain-Barré syndrome, not multiple sclerosis. MS does not usually present with paralysis but rather with muscle weakness and sensory disturbances.
C. Early signs of multiple sclerosis often include areas of numbness, weakness in the legs, and visual problems such as optic neuritis. These symptoms result from demyelination and nerve damage in the central nervous system.
D. Choreiform movements and loss of facial expression are associated with Huntington's disease, not multiple sclerosis.

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A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

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