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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Current anticoagulant use B. Blood pressure of 160/85 mm Hg C. Complete neurologic assessment D. Current treatment for client's peptic ulcer disease

Correct Answer is A

Explanation

A. Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
B. While blood pressure is important to monitor, it is secondary to assessing anticoagulant use since high blood pressure alone does not contraindicate t-PA administration.
C. A complete neurologic assessment is important for determining the extent of the stroke but is not the immediate priority before administering t-PA.
D. While treatment for peptic ulcer disease is relevant, it is not directly related to the immediate risk factors for t-PA administration compared to anticoagulant use.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with a new diagnosis of multiple sclerosis. Which manifestations would the nurse expect to see that are common early signs of multiple sclerosis?

Correct Answer is C

Explanation

A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

Correct Answer is A

Explanation

A client with chronic pain is using aspirin regularly to control her pain symptoms. She presents to the hospital with abdominal pain, pale skin, afebrile, and a blood pressure (BP) of 83/45 mm Hg. Which type of shock is the client most likely experiencing?

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following responses from the client shows understanding of the teaching plan?

A client is exploring treatment options after being diagnosed with age-related cataracts that affect their vision. What treatment is most likely to be used in this client's care?

A client with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, and the client is experiencing fatigue and mild nausea. Which nursing action is the highest priority?

A nurse is caring for a 55-year-old client who is 2 hours postoperative after having a total abdominal hysterectomy. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown,dropdownand dropdown

A client with Meniere disease is instructed to modify his diet. The nurse would explain that which item would be acceptable for the client to include?