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 B

Explanation

A. The time of the burn helps in understanding how long the client has been exposed and may influence the assessment of burn progression, but it does not directly determine the severity.
B. The depth of the burn is the primary factor in assessing burn severity. It determines the level of tissue damage and guides treatment decisions. Depth classifications include superficial, partial-thickness, and full-thickness burns.
C. The cause of the burn is important for treatment considerations and understanding the mechanism of injury but does not impact the assessment of burn severity.
D. The location of the burn affects the potential for complications and functional impairment but is secondary to the depth in determining overall burn severity.

A. Encourage the client to increase fluid intake. B. Wear a mask when caring for the client. C. Prepare to administer an antibiotic to the client. D. Place the client in a private room. E. Place the client on contact precautions.

Correct Answer is ["A","B","D"]

Explanation

A. Encourage the client to increase fluid intake: This is important to prevent dehydration, which can be a complication of influenza.
B. Wear a mask when caring for the client: Influenza is a highly contagious virus, and wearing a mask can help prevent the spread of infection.
C. Prepare to administer an antibiotic to the client: Antibiotics are not typically used to treat influenza, which is a viral infection. However, if a bacterial infection develops as a complication, antibiotics may be necessary.
D. Place the client in a private room: Isolating the client in a private room can help prevent the spread of influenza to other patients and healthcare workers.
E. Place the client on contact precautions: Influenza is primarily spread through respiratory droplets, so droplet precautions are appropriate. Contact precautions are not necessary for influenza.

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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

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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