A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
Poor impulse control
Deficits in the right visual field
Unable to discriminate words and letters
Motor retardation
The Correct Answer is A
Choice A reason: A stroke involving the right cerebral hemisphere can affect the cognitive and emotional functions of the brain, such as judgment, impulse control, and emotional regulation³. This can lead to risky or inappropriate behaviors, such as acting impulsively or disregarding social norms. Therefore, the nurse should monitor the client for poor impulse control and provide appropriate interventions, such as education, cueing, feedback, and environmental modifications.
Choice B reason: A stroke involving the right cerebral hemisphere can affect the visual functions of the brain, such as depth perception, spatial orientation, and visual recognition³. However, the deficits are usually in the left visual field, not the right, because the right side of the brain controls the left side of the body and the environment. Therefore, the nurse should monitor the client for deficits in the left visual field, not the right.
Choice C reason: A stroke involving the right cerebral hemisphere can affect the abstract reasoning functions of the brain, such as understanding metaphors, humor, or sarcasm. However, the ability to discriminate words and letters is more related to the language functions of the brain, which are mainly controlled by the left cerebral hemisphere. Therefore, the nurse should monitor the client for language deficits, such as aphasia or dysarthria, if the stroke involves the left cerebral hemisphere, not the right.
Choice D reason: A stroke involving the right cerebral hemisphere can affect the motor functions of the brain, such as movement, coordination, and balance³. However, the motor retardation, which is a slowing down of physical and mental activity, is more related to the mood functions of the brain, which are mainly controlled by the frontal lobe of the brain. Therefore, the nurse should monitor the client for motor retardation if the stroke involves the frontal lobe, not the right cerebral hemisphere.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Take isoniazid with an antacid. This answer is incorrect because taking isoniazid with an antacid can reduce the absorption and effectiveness of the drug. Isoniazid should be taken on an empty stomach, one hour before or two hours after meals.
Choice B reason: Drink at least 8 ounces of water when you take the pyrazinamide tablet. This answer is incorrect because drinking water with pyrazinamide is not necessary, as this drug does not cause dehydration or kidney problems. However, drinking plenty of fluids is generally recommended for clients with tuberculosis to prevent dehydration and help clear the lungs of secretions.
Choice C reason: Expect your sputum cultures to be negative after 6 months of therapy. This answer is incorrect because expecting sputum cultures to be negative after 6 months of therapy is unrealistic and misleading. The duration of treatment for tuberculosis varies depending on the type and extent of the infection, the drug regimen, and the client's response to the therapy. Some clients may need longer than 6 months to achieve negative sputum cultures.
Choice D reason: Provide a sputum specimen every 2 weeks to the clinic for testing. This answer is correct because providing sputum specimens regularly is important to monitor the effectiveness of the treatment and to determine when the client is no longer infectious.
Correct Answer is C
Explanation
Choice A reason: Performing CPT immediately after the child eats is not a good action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. CPT involves techniques such as percussion, vibration, and postural drainage that help to loosen and remove mucus from the lungs. Performing CPT right after eating can cause nausea, vomiting, or aspiration, especially if the child has gastroesophageal reflux disease (GERD), which is common in cystic fibrosis. The nurse should plan to perform CPT at least 1 hour before or after meals.
Choice B reason: Percussing each lung segment for 15 min is not a necessary action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Percussion is a technique that involves clapping the chest with a cupped hand to create vibrations that loosen the mucus in the airways. Percussion can be done manually or with a mechanical device. The duration of percussion depends on the amount and location of the mucus, but it is usually done for 3 to 5 min per lung segment. Percussing for 15 min per segment can be excessive and cause bruising, pain, or fatigue.
Choice C reason: Administering albuterol prior to CPT is a beneficial action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Albuterol is a bronchodilator that helps to relax the smooth muscles of the airways and improve airflow. Administering albuterol before CPT can enhance the effectiveness of the airway clearance techniques by opening up the airways and making it easier to cough up the mucus.
Choice D reason: Performing vibration during the client’s inspirations is not a correct action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Vibration is a technique that involves applying pressure and shaking the chest wall during exhalation to help move the mucus out of the lungs. Vibration can be done manually or with a mechanical device. Performing vibration during inspiration can interfere with the inhalation of air and oxygen, and reduce the effectiveness of the technique.
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