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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Corticosteroids are not typically associated with causing thrombocytopenia. Their primary effects are on the immune system and metabolism.
B. Corticosteroids more commonly cause hypertension due to fluid retention and increased sensitivity to vasoconstrictors, rather than hypotension.
C. Corticosteroids cause immunosuppression by inhibiting the function of various immune cells and reducing the production of inflammatory cytokines. This increases the risk of infections.
D. Anemia is not a direct effect of corticosteroid use. The medication's impact on the bone marrow typically affects the white blood cell count, particularly in causing leukocytosis, rather than leading to anemia.
Correct Answer is ["A","B","D"]
Explanation
A. The fingerstick blood glucose level of 55 mg/dL at 1130 indicates hypoglycemia, which requires immediate attention to prevent further complications such as loss of consciousness or severe symptoms.
B. The client's report of shakiness, hunger, and cool, diaphoretic skin are signs of hypoglycemia, especially given the low blood glucose level. This requires prompt intervention to manage the blood glucose level.
C. The temperature of 37.8 °C (100 °F) is slightly elevated but does not require immediate follow-up unless there are other symptoms of infection or significant changes.
D. The elevated heart rate of 118/min could indicate an underlying issue such as dehydration, hypoglycemia, or infection. It requires further evaluation in the context of other findings.
E. The SpO2 of 95% on room air is within an acceptable range and does not require immediate follow-up unless there are other signs of respiratory distress or worsening condition.
F. The HbA1c of 8.01% reflects long-term glucose control but is not an immediate concern for follow-up in the acute setting. It is important for overall management but not an urgent issue for this particular scenario.
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