A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Impaired sense of humor

Poor judgment

Intellectual impairment

Loss of depth perception

Answer and Explanation

The Correct Answer is C

Choice A reason: Impaired sense of humor is not a common finding for a client who had a stroke involving the left cerebral hemisphere. Impaired sense of humor is more likely to occur after a stroke involving the right cerebral hemisphere, which is responsible for processing humor, irony, and sarcasm.

Choice B reason: Poor judgment is not a typical finding for a client who had a stroke involving the left cerebral hemisphere. Poor judgment is more likely to occur after a stroke involving the frontal lobe, which is involved in executive functions, such as planning, reasoning, and decision making.

Choice C reason: Intellectual impairment is a possible finding for a client who had a stroke involving the left cerebral hemisphere. The left cerebral hemisphere is dominant for language and analytical thinking in most people. A stroke affecting this hemisphere can impair the ability to speak, read, write, calculate, and comprehend information.

Choice D reason: Loss of depth perception is not a frequent finding for a client who had a stroke involving the left cerebral hemisphere. Loss of depth perception is more likely to occur after a stroke involving the occipital lobe, which is involved in visual processing, or the parietal lobe, which is involved in spatial awareness.

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Correct Answer is C

Explanation

Choice A reason: "Use simple, childlike statements when speaking." This response is not appropriate because it can be demeaning and disrespectful to the client. The client is an adult who knows what they want to say, but they have difficulty saying it. Using simple statements is helpful, but they should not be childlike or patronizing.

Choice B reason: "Use a higher pitched tone of voice when speaking." This response is not appropriate because it can be irritating and confusing to the client. The client may have normal hearing, or they may have hearing loss due to age or stroke. Using a higher pitched tone of voice can make the speech harder to understand and may imply that the client is not intelligent.

Choice C reason: "Incorporate nonverbal cues in the conversation." This response is appropriate because nonverbal cues, such as gestures, facial expressions, and drawings, can help the client understand and express themselves better. Nonverbal cues can also reduce frustration and anxiety for both the client and the family member.

Choice D reason: "Ask multiple choice questions as part of the conversation." This response is not appropriate because it can be overwhelming and stressful for the client. Multiple choice questions can be hard to process and remember for someone with aphasia. It is better to ask yes or no questions, or to provide options with visual cues.

A. Difficulty moving the upper extremities B. Stiffness in the lower extremities C. A reddened area over the sacrum D. Difficulty hearing some types of sounds

Correct Answer is C

Explanation

Choice A reason: Difficulty moving the upper extremities is not a complication of immobility, but a result of the stroke. A stroke can damage the part of the brain that controls movement, sensation, or coordination of the limbs, causing hemiparesis (weakness) or hemiplegia (paralysis) on one side of the body. The nurse should assist the client with passive or active range of motion exercises to prevent muscle atrophy and contractures.

Choice B reason: Stiffness in the lower extremities is not a complication of immobility, but a result of the stroke. A stroke can affect the muscle tone of the limbs, causing spasticity (increased muscle tension) or flaccidity (decreased muscle tone) on one side of the body. The nurse should apply splints or braces to prevent deformities and provide massage or stretching to relieve stiffness.

Choice C reason: A reddened area over the sacrum is a complication of immobility, and a sign of a pressure injury. A pressure injury is a localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear. The sacrum is a common site for pressure injuries, as it is a bony prominence that bears the weight of the body when lying down. The nurse should reposition the client every 12 hours, provide skin care, and use pressure relieving devices to prevent pressure injuries.

Choice D reason: Difficulty hearing some types of sounds is not a complication of immobility, but a result of aging or other factors. Hearing loss can occur due to various causes, such as exposure to loud noise, ear infections, earwax buildup, or ototoxic medications. The nurse should assess the client's hearing and use communication strategies, such as speaking clearly, facing the client, and reducing background noise.

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A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Nursing Test Bank

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Explanation

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