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 D

Explanation

A. Decreased cardiac output is not a primary concern with chlorine exposure, which primarily affects the respiratory system.
B. Hypovolemia is not directly related to chlorine gas exposure. The primary concern is respiratory damage.
C. Chronic pain is not an immediate or primary finding in chlorine gas exposure; the focus is on acute respiratory effects.
D. Pulmonary edema is a common and severe consequence of chlorine gas inhalation due to the corrosive effect of chlorine on the respiratory tract, leading to fluid accumulation in the lungs.

A. Hypovolemic shock B. Obstructive shock C. Cardiogenic shock D. Septic shock

Correct Answer is A

Explanation

A. Hypovolemic shock is characterized by low blood pressure, pale skin, and abdominal pain due to significant fluid loss or hemorrhage. The client's symptoms, including hypotension and abdominal pain, suggest a reduction in blood volume potentially caused by gastrointestinal bleeding or ulceration, which is consistent with chronic aspirin use.
B. Obstructive shock is due to a physical obstruction of blood flow, such as a pulmonary embolism or cardiac tamponade, which does not directly correlate with the client's presentation of symptoms.
C. Cardiogenic shock results from severe heart failure and is typically accompanied by signs of heart dysfunction, not just low blood pressure and abdominal pain.
D. Septic shock is associated with infection and systemic inflammation, often presenting with fever and other signs of infection, which the client is not exhibiting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The emergency department (ED) staff has been notified of the imminent arrival of a client who has experienced respiratory exposure to the chemical agent chlorine. Which finding should the anticipate with this exposure?

Correct Answer is D

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?

Correct Answer is A

Explanation

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